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Application Form for Interbank GIRO - AXA Life Insurance Singapore

Application Form for Interbank GIRO - AXA Life Insurance Singapore

Application Form for Interbank GIRO - AXA Life Insurance

*NSG1GIROF* Application for premium payment by Interbank GIRO Part A: Application For Interbank Giro Part 1: For applicant's completion (fill in the spaces indicated with √ ) Name of bank: Name of billing organisation: AXA Life Insurance Singapore Pte Ltd Policyholder’s name Branch: Policy number a) I or We * instruct you to process AXA Life Insurance Singapore Pte Ltd’s instructions to debit my or our * account. b) You are entitled to reject AXA Life Insurance Singapore Pte Ltd’s debit instruction if my or our * account does not have sufficient funds and charge me or us * a fee for this. You may also at your discretion allow the debit even if this results in an overdraft on the account and impose charges accordingly. c) This authorisation will remain in force until terminated by your written notice sent to my or our * address last known to you or upon receipt of my or our written revocation through AXA Life Insurance Singapore Pte Ltd. Part B: My or our personal particulars Bank Account holder’s name Contact number(s) Note: * Please delete where applicable. + If Bank Account holder is NOT the policyholder, please furnish NRIC no. of Bank Account holder. Bank account number Signature or thumbprint # or company stamp # For thumbprints, please go to the branch with your identification document for verification. NRIC no. of Bank Account holder + (As in bank’s records) Part C: For billing organisation’s completion Bank Branch Billing Organisation's account number 7 1 7 1 0 0 3 0 0 3 9 2 1 8 0 9 5 Bank Branch Account number to be debited Policy number Part D: For bank use only To: Adviser and Customer Service AXA Life Insurance Singapore Private Limited 8 Shenton Way #27-02 AXA Tower Singapore 068811 This application is hereby REJECTED (please tick) for the following reason(s): o Signature or thumbprint* differs from bank's records o Signature or thumbprint* incomplete or unclear* o Account operated by signature or thumbprint* o Wrong account number o Amendments not countersigned by customer o Others: Name of approving officer Authorised signature Date AXA Life Insurance Singapore Private Limited (Company Reg. No. 199903512M) 8 Shenton Way #27-02 AXA Tower Singapore 068811 Axa Customer Centre #B1-01 Tel: 1800 880 4888 Fax: 6880 5501 Website: www.axa.com.sg 1 of 1 09/2013

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