FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIM

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1 Payment details Heading to be dropped in here... Guidance notes Please complete in BLOCK CAPITALS the section which is appropriate for your method of payment and return the form, along with your application form, to your financial adviser or Friends Provident International. DO NOT send the completed form to your bank or building society. Warning: Please note that cash is not acceptable as a premium payment method. Any payments made in cash may not be returned. For monthly payments (available for five year terms or more, only) a Banker s standing order, Interbank giro from a local bank account (Singapore dollar payments only), and Credit Card Authority (VISA, Eurocard and Mastercard only) are acceptable methods of payment. For annual payments a Banker s standing order, Interbank giro from a local bank account (Singapore dollar payments only), credit card authority (VISA, Eurocard & Mastercard only), draft and telegraphic transfer are acceptable. For annual payments by Telegraphic Transfer Complete Section A. For annual payments by Banker s Draft Complete Section B. For monthly or annual payments by Banker s Standing Order Complete Section C. For monthly or annual payments by Credit Card Complete the relevant form overleaf. For monthly or annual payments by Interbank Giro Complete the relevant form overleaf. Please sign Section D in all cases. Bank instruction letter Please use BLOCK CAPITALS. To be completed in all cases unless paying by credit card or Interbank giro. Please note that some banks insist that their own bank instruction form is used, so you should check with your bank that they will accept this document. Name and full postal address of your bank To: The Manager (Bank) Bank address (PO Box mandatory) Telephone number (mandatory) Account number Account currency (must be completed if the account is multi-currency) Account holder s name Sort code (if applicable) SWIFT/BIC code (if applicable) IBAN (if applicable) Section A: Telegraphic transfers On my/our behalf please prepare a telegraphic transfer and carry out the transaction indicated within 48 hours of you receiving this instruction. Please remit to HSBC Singapore, 21 Collyer Quay, #03-01 HSBC Building, Singapore a SWIFT Payment Order to SWIFT Code: HSBCSGSG. The beneficiary account name is Friends Provident International Limited (Singapore Branch) and the beneficiary account number is is for SGD only. For the other currencies account numbers, please refer to p.31 Our bank details section. The reference number below (see Section D) must be quoted by the bank on all advices. SG$ US$ HK$ GB EU (figures) SG$ US$ HK$ GB EU (words) Please charge the amount of the payment together with any bank and agent bank s charges to my/our account. 31

2 Section B: Drafts On my/our behalf please prepare a draft and carry out the transaction indicated within 48 hours of you receiving this instruction. On receipt of this letter please prepare a draft of: (tick one box only) SG dollar draft (drawn on a bank in Singapore) US dollar draft (drawn on a bank in New York) HK dollar draft (drawn on a bank in Hong Kong) Sterling draft (drawn on a bank in the United Kingdom) Euro draft (drawn on a bank in the European Economic and Monetary Union (EMU)) payable to Friends Provident International Limited (Singapore Branch), quoting the reference given below, for exactly (figures) (words) USD, GBP and Euro drafts: After preparation of the draft, please airmail it at my/our own cost, together with a copy of this instruction, immediately to Friends Provident International Limited, Royal Court, Castletown, Isle of Man, British Isles IM9 1RA. SGD and HKD drafts: After preparation of the draft, please airmail it at my/our own cost, together with a copy of this instruction, immediately to Friends Provident International Limited (Singapore Branch), 4 Shenton Way, #11-04/06, SGX Centre 2, Singapore Section C: Banker s standing order On my/our behalf please pay by bankers remittance and carry out the transaction indicated within 48 hours of you receiving this instruction. Please charge the amount of the payment below and any bank and agent bank s charges to my/our account. SG$ US$ HK$ GB EU (figures) SG$ US$ HK$ GB EU (words) on the day of (month) (year) and on the same day monthly annually Section D: Signatures Yours faithfully, Signature(s) Date (DD/MM/YYYY) My/Our address Please state your policy number as reference number to be quoted by the bank on all advices Our bank details HSBC Singapore, 21 Collyer Quay, #03-01 HSBC Building, Singapore SWIFT code: HSBCSGSG SGD Account number: Account name: FPIL (SG BR)-G TERM P AC SGD USD Account number: Account name: FPIL (SG BR)-G TERM P AC USD HKD Account number: Account name: FPIL (SG BR)-G TERM P AC HKD GBP Account number: Account name: FPIL (SG BR)-G TERM P AC GBP EUR Account number: Account name: FPIL (SG BR)-G TERM P AC EUR 32 Friends Provident International Global Term Application form

3 Application for Credit card authority This form supersedes any previous instructions held. Please use BLOCK CAPITALS. I authorise Friends Provident International to charge the premium below, to my credit card account for this insurance policy. This authorisation is to remain in effect until I cancel it by written notification to Friends Provident International at least 30 days in advance of the intended date of cancellation. Name of cardholder Bank name Credit card number Expiry date (MM/YY) Card provider Mastercard VISA Credit Card Eurocard Currency SG$ US$ HK$ GB EU with sum of (enter premium amount, if known) Collected on the (premium due date) (DD/MM/YYYY) and on the same day until further notice Monthly Annually Address of credit card holder (as held by the card provider) Signature Date (DD/MM/YYYY) Important information 1 Please note that debit cards cannot be accepted for premium payments. 2 Please note that some credit cards cannot be used outside their country of issue and therefore we strongly recommend that you contact your card issuer to ensure your card can be used in this instance. * I understand that Friends Provident International will complete these once the premium amount is finalised. Once complete, please return this Credit card authority to Friends Provident International as follows: By post To your regional office or our Isle of Man office: Friends Provident international. Royal Court, Castletown, Isle of Man, British Isles, IM9, 1RA. By fax To our secure locations in the Isle of Man: +44 (0) or UK +44 (0) Please do not complete this page if you intend ing (or scanning and ing) this form back to us. We can only accept this form via post or fax. Details can be accepted electronically via our secure website at Please note: Friends Provident International is committed to comply with the Payment Card Industry Data Security Standard (PCI DSS). To comply with PCI DSS, we are unable to accept any containing credit card data. 33

4 Heading Application to be dropped for Interbank in here... giro (Singapore dollar payments only) Section A To be completed by the applicant Only available in Singapore dollars for clients with local bank accounts. This form must be submitted in original-inked. Please use BLOCK CAPITALS. As the Interbank GIRO arrangement may take up to two months to be effective, you are required to make the first premium by cheque or by credit card. To: The Manager Name and full postal address of (Bank) my/our bank Bank address (PO Box mandatory) Name of billing organisation ( BO ) Friends Provident International Limited Name of Policyholder(s) a) I/We hereby instruct you to process the BO s instructions to debit my/our account. b) You are entitled to reject the BO s debit instruction if my/our account does not have sufficient funds and charge me/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. Please advise us in writing by giving one month s notice before the next deduction date. My/Our bank account name My/Our bank account number Account holder(s) contact number(s) My/Our company stamp/signature(s) Thumbprint(s) (as in bank s record) Thumbprint must be verified by the bank Date of signature (DD/MM/YYYY) Section B The following is to be completed by Friends Provident International (Singapore Branch) Bank Branch Account number Friends Provident International Limited Bank Account number to be debited Bank Branch Account number Friends Provident International Limited (Singapore branch) Customer s reference number Section C To be completed by the bank To: Friends Provident International Limited (Singapore branch) This application is hereby approved. (Please tick.) This application is hereby rejected for the following reason(s) indicated below. (Please tick.) Signature/Thumbprint differs from financial Wrong account number institution s records Signature/Thumbprint incomplete/unclear Account operated by Signature/Thumbprint Amendments not countersigned by customer Other (please specify below) Name of approving/rejecting officer (please print) Authorised signature Date of signature (DD/MM/YYYY) 35

5 Friends Provident International Limited (Singapore branch): 4 Shenton Way, #11-04/06 SGX Centre 2, Singapore Telephone: Fax: Website: Registered in Singapore No. T06FC6835J. Licensed by the Monetary Authority of Singapore to conduct life insurance business in Singapore. Member of the Life Insurance Association of Singapore. Member of the Singapore Financial Dispute Resolution Scheme. Friends Provident International Limited Registered and Head Office: Royal Court, Castletown, Isle of Man, British Isles, IM9 1RA. Telephone: +44(0) Fax: +44(0) Incorporated company limited by shares. Registered in the Isle of Man, number Authorised by the Isle of Man Financial Services Authority. Friends Provident International is a registered trade mark of the Aviva group. PROTECTION PAYMENT (47807)