6 BPI/MS Insurance Corporation CREDIT CARD PAYMENT FORM INSURANCE INFORMATION: “Customer Name: Mobile Number: Home: Email Address: Insurance Premium Due: CREDIT CARD INFORMATION: Bank Name: Cardholder Name: Fcacas Revision 01 October 1, 2018, Office: Policy Number: Policy inception Date: Cardholder Number: Expiry Date: “Customer name and est cardioder name should be he came PAYMENT INFORMATION: ‘Mark (X) the payment options you wish to apply. Charge my insurance: REQUIREMENTS: * Photocopy of the Credit Card (front only) \Via installment: (minimum insurance Premium Due of Php 3,000 for 3, 6 & 9 mos.) (minimum insurance Premium Due of Php 15,000 for 12 mos.) Real 0% Installment 0% Installment (BPVBFB Credit Card) (BDO/HSBC/Chinabank issued credit cards) 3 months 3 months 6 months 6 months 9 months 9 months 12 months ‘Straight Charge (One time payment using any Visa or Mastercard credit card) * Photocopy of Cardholder's valid government issued ID with signature. IMPORTANT REMINDER: Insurance Premium Due, Policy inception Date and payment options are subject to validation at the time of ‘charging. Please submit this form to the BPI/MS Insurance Corporation office nearest you. A | agree to be bound by the Terms and Conditions of this form. | certify that the information provided here are true and correct. et (a » BPI/MS Insurance =CorporationBPI/MS Policy Terms and Conditions 1. The Insurance Policy premium to BPI/MS shall be paid through the enrolled credit card. 2. Charging of the Insurance Premium due against the enrolled credit card is based on the chosen installment terms, ifany. 3, In case of failed charge payment for the enrolled premium, BPI/MS will contact the cardholder to inform him/her of the unsuccessful attempt. 4, Cardholder is aware that the enrollment to this payment facility is active and in-force for the duration of the policy coverage. 5. In case of cancellation / expiration /termination of the credit card, cardholder must enroll another credit card. Failure to enroll another credit card shall not give rise to any liability on the part of BPI/MS if the policy cancelled for non-payment. Credit Card Installment Terms and Conditions 1. BPI/MS credit card installment payment is open to a cardholder with good credit standing of the following cards: - BPI Credit Cards(Blue MasterCard, Gold MasterCard, Petron-BP! MasterCard, BP! WorldPerks MasterCard, BP! SkyMiles MasterCard, BPI SkyMiles Platinum MasterCard, BPI Amore Visa, BPI Amore Visa Platinum, Edge MasterCard and BPI Family Credit Cards. = HSBC Red Mastercard, HSBC Premier World Mastercard, HSBC Platinum Visa, HSBC Cash Back Visa, HSBC Visa = China Bank Prime Mastercard, China Bank Platinum Mastercard and China Bank World Mastercard ~ BDO issued Visa and Mastercard credit cards 2. Cardholder can avail of the 0% installment subject to the submission of the required forms and approval within the agreed turnaround time. 3. To avail of the products and services, cardholder must either; * Personally present his/her credit card to any BPI MS Insurance Corporation office and sign the chargeslip when the transaction is approved; or ‘+ Fill out the Credit Card Payment Form and send it to the nearest BPI/MS Sales Office. 4, The terms and conditions governing the issuance of the BPI/BFB, BDO, HSBC and China Bank Credit Card, and the reminders and other provisions contained in the card carrier, statement of account, charge slips and other documents or instruments, which are made an integral part hereof by reference, shall likewise be resorted to in instances where they are applicable. Insurance