Credit Card

Enrollment form
PRU LIFE INSURANCE CORPORATION OF U.K.
Policyowner: 9/F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio,
Last name First name M.I. 1634 Taguig City, Philippines
Customer helpdesk: (632) 683 9000, (632) 884 8484, (632) 887 LIFE
Policy no.: within Metro Manila, 1 800 10 PRULINK for domestic toll-free
Email: [email protected] Website: www. prulifeuk.com.ph
Billing option (Please check)
One-time payment Recurring payment (Required for monthly mode) Amount :
Primary Card Alternate card
Visa Mastercard Visa Mastercard
Cardholder: Cardholder:
Last name First name M.I. Last name First name M.I.
Relationship to Policyowner: Relationship to Policyowner:
Contact nos.: Contact nos.:
Card no.: Card no.:
Expiry date: Expiry date:
Month Year Month Year
Bank issuer: Bank issuer:
Cardholder declaration and authorization Cardholder declaration and authorization
I hereby declare under the penalty of perjury that the information provided above is true and correct. I hereby declare under the penalty of perjury that the information provided above is true and correct.
I hereby also state that I have read and agreed to the terms and conditions stipulated at the back of this I hereby also state that I have read and agreed to the terms and conditions stipulated at the back of this
form. By affixing my signature below, I hereby authorize Pru Life UK to charge the payments due for form. By affixing my signature below, I hereby authorize Pru Life UK to charge the payments due for
the insurance application/policy number indicated above to my credit card account. I likewise confirm the insurance application/policy number indicated above to my credit card account. I likewise confirm
that the payments herein charged to my credit card account are valid and accurate, despite the that the payments herein charged to my credit card account are valid and accurate, despite the
absence of my signature in the sales slip or terminal receipt for such payments, I further waive the absence of my signature in the sales slip or terminal receipt for such payments, I further waive the
requirement that Pru Life UK prepare, issue, submit or deliver to me a true and completed copy of the requirement that Pru Life UK prepare, issue, submit or deliver to me a true and completed copy of the
sales slip or terminal receipt covering these payments.This authorization will be cancelled after five (5) sales slip or terminal receipt covering these payments.This authorization will be cancelled after five (5)
days from receipt by Pru Life UK of my written notice to cancel it. days from receipt by Pru Life UK of my written notice to cancel it.

Cardholder’s signature: Cardholder’s signature:

Effectivity date: Effectivity date:
Policyowner’s signature: Policyowner’s signature:
(if other than the cardholder) (if other than the cardholder)
 Terms and conditions

Credit card enrollment requirements Hold or stop billing request

Card Type Visa and Mastercard, both local and international A written request must be submitted to Pru Life UK branches or through your servicing agent at
debit cards are not allowed least five (5) working days before premium due date.
Card Ownership Valid credit cards for enrollment are those owned by the
policyholder or immediate family members (e.g. parents or For request to hold billing, effectivity date and duration must be indicated. All back premiums
siblings, if single; spouse or children, if married) shall be collected upon resumption of credit card billing.
Eligible Plans All peso & dollar-denominated plans except PIA
Premium Initial & renewal premiums. APL/loan repayment via credit card Change in credit card details
is not allowed. Please update Pru Life UK of your new card details by submitting the following documents to any
Requirements (1) Duly accomplished Credit Card Enrollment Form of our branches or through your servicing agent to avoid unsuccessful billing due to expired, lost,
(2) Photocopy of the credit card's front side stolen or replaced credit cards.
(3) KYC for third party payor, if applicable
For New Business applications, the credit card enrollment
Change in card Written notice signed by the policyowner or agent
requirements must be attached to the Insurance Application Form
expiry date

Credit card billing Change in card (1) Duly accomplished Credit Card Enrollment Form
number (2) Photocopy of the credit card's front side
Credit card billing of policies enrolled to the recurring billing option is done on the policy's due
date provided that the policy is updated. If due date falls on a weekend or a holiday, billing is done
on the following working day. Declined transactions are automatically rebilled for two (2) Change of payment method
consecutive weeks from the date of first unsuccessful billing. If subsequent billing attempts are Policyowner must submit a duly accomplished Policy Amendment Request Form at least five (5)
unsuccessful, you will be notified by mail to settle youroutstanding premium in cash or check working days before premium due date. Enrollment to automatic debit arrangement (ADA)
through any of our Pru Life branches or accredited banks. facility or submission of post-dated checks (PDC) is required for policies under monthly mode of
payment.
Pru Life UK's credit card billing is subject to the security policies of the card issuer-bank.You may
be required to call your card issuer to authorize our premium billing in cases involving large
amount, unusual billing location, unusual transactions or unsettled balance.

Billing of the alternate card is activated in case of declined billing attempt on the primarycard.
Re-billing is not applicable on policies under one-time billing option.

LO/CCE/JEC/052418