PT.

ASURANSI ALLIANZ UTAMA INDONESIA

INSURANCE PREMIUM PAYMENT AUTHORIZATION FORM

If you would like to enjoy the convenience of insurance premium payment using your Visa or Master card, simply fill out all the information
below with your Visa or Master card data. You may return by fax to 06221-25989998-97. We will debit your Visa or Master card appropriate
as per your requested premium payment.

VISA CARD ACCOUNT MASTER CARD ACCOUNT

Name of Bank (must be filled) Name of Bank ( must be filled )

Name on Visa card ( exactly as printed ) Name on Master card ( exactly as printed )

Visa card number Master card number

Expiration date Your tel. no. Expiration date Your tel. no.
DD-MM-YY DD-MM-YY

10-Jul-20 10-Jul-20
Today’s date Signature Today’s date Signature

Details of payment :

* Amount

* Policy no / Cover Note :