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PRU LIFE UK.33 Head afer: 9/F Uptown Place Tower, ast 1th Dive, Uptown Bonar, 134 Tap Pines (Fc rine: (32 83500, (432) a ane ‘Customer helpdesk (52 887 (57-5652) whiner Mari 1800-10 PRULINE 1 0010778546) desi tie Credit Card Enrollment Form E all cost eta com py Webate! wor plesk om ph Policyowner: Billing option (Please check) (1) one-time payment Amount : Policy no.: a Recurring payment jogos tr rent re) Primary card ‘Altemate card ( Visa O Mastercard O Visa ( Mastercard Cardholder: Cardholder: Relationship to Policyowner: Contact nos.: Card no.: [- 1 Expiry date: CT] CREE Bank issuer: Carhoter aciraton and atorzaton seca rence meetianter ee ee arma eet neaninneeeeeans Soo etace nn eerat arom Saieenecaeeereiarome mae Facto nerraaicne eaves ipiaaton ecameene rarer arora eer anaes Relationship to Policyowner: Contact nos. Card no: (LTT) Expiry date: [1 LL Bank issuer: Cardholder declaration and authorization ‘hry deters the nay ay tal nora provied aon iin ard aot nyo sta ve reedend agra ts ard casos sips each ie ‘tm aftangnysratr bw nraty aay Pe Uo care pet ee hs ‘sarc pearly nun cate toe tony eta ocr awa coe Pat ‘he peymenthrt ape my oo osm val daca dopa ern ny satire sos isortamalrco fr sscyment rite eens Pat ‘tt trropars tsa ceteris telcos ey ete saes verte! ‘Seton ten ara Teoretonv crated are) aso ec J Cardholder's signature: Cardholder's signature: Effectivity date: Effectvity date: Policyowner's signature: Policyowner's signature: (Worertente conta ater bene srt

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