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CREDIT CARD AUTHORISATION FORM

I authorise The Great Eastern Life Assurance Company Limited (the “Company”) to debit my Credit Card account to pay for my own and/or my Family
Member’s proposal/ policy below. I have read the Terms & Conditions set out in Section C and agree to be bound by the said terms and conditions.
“Family Member” shall mean spouse, children, parents, parents-in-law, son-in-law, daughter-in-law, brothers and sisters. Capitalised terms which are
not defined herein shall have the same meanings ascribed to them in the relevant policy document.
By providing the information set out below, I agree and consent to the Company and its related corporations (collectively, the “Companies”), as well as
their respective representatives and agents, collecting, using, disclosing and sharing amongst themselves my personal data, and disclosing such
personal data to the Companies’ authorised service providers and relevant third parties for purposes reasonably required by the Companies to effect the
payment authorisation herein. These purposes are set out in the Company’s Privacy Statement, which is accessible at
greateasternlife.com/sg/en/privacy-and security-policy.html and which I confirm I have read and understood.
(If Cardholder is not the Proposer/ Policyholder, please submit a copy of the Cardholder’s NRIC/ Passport/ FIN/ Driving Licence for verification purpose)

A POLICY DETAILS OF PROPOSER/ POLICYHOLDER

Policy Number Policyholder’s Name NRIC/ Passport Relationship to

No./ FIN No. Cardholder

1 0 9 2 2 2 2 9 3 3 3 Great SupremeHealth

B DEDUCTION INSTRUCTION

GREAT 1. To deduct premium in excess of CPF withdrawal limit (for GSH); or

SupremeHealth To deduct balance premium required after CPF MediSave deduction (for GCS/ESH)
Policy (GSH)
◻ Initial / Current Premium only
GREAT
CareShield Policy Initial / Current & Future Premiums
(GCS)
2. Full Premium
Eldershield
Supplementary ◻ Initial / Current Premium only (No premium deduction from CPF MediSave Account for initial / current premium only) ◻ Initial
Policy (ESH) / Current & Future Premiums (No premium deduction from CPF MediSave Account for initial / current & future premiums)

Life / Accident & ◻ Initial / Current Premium only*

Health Policy
◻ Initial / Current & Future Premiums*
* Applicable to new SGD regular premium policies submitted from 15 October 2020 onwards. Not applicable for regular Universal Life policies and
Dependants' Protection Scheme policies. Only OCBCGE Cashflo card can be used for renewal of policies launched from July 2014 and inforce
by 14 October 2020.

OTHER VISA/ MASTERCARD CREDIT CARD DETAILS

Name on Credit Card NRIC/Passport No./ FIN No. of Cardholder

John Stevenson

Credit Card No. Expiry Date (MMYYYY)

4444-1234 5678-9101
05/25

Signature of Cardholder Contact No. of Cardholder Date (DD/ MM/ YYYY)

(As per Credit Card)

1 Pickering Street #01-01

Great Eastern Centre
 Singapore 048659 t (65) 6248 2888 greateasternlife.com greateasterngeneral.com

The Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G) CS243 Aug 2024 1 Pickering Street #01-01 Great Eastern Centre Singapore 048659
Great Eastern Holdings Limited (Reg. No. 1999 03008M) | The Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)
Tel: 1800-248 2888 (Local), (65) 6248 2888 (Overseas)
Great Eastern General Insurance Limited (Reg. No 1920 00003W)
Email: [email protected] Website: greateasternlife.com
Email: [email protected] Website: greateasternlife.com

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C TERMS & CONDITIONS

1. “Initial Premium” shall mean the first outstanding premium paid (based on the payment mode indicated in the proposal form) that is payable before the
policy proposed is issued.
2. “Initial Premium” shall mean the premiums for the first two (2) months if monthly premium is selected, except for policyholder who has signed up for
eGIRO or recurring credit card payment for both initial and future premiums.
3. “Future premiums” shall mean the subsequent premium payments due after the policy is issued.
4. If the cardholder is not the policyholder of the policy, he/she has no right under the Contracts (Rights of the Third Parties) Act to enforce any of the terms
and conditions of the policy. The Company shall not be obligated to take any instructions from the cardholder in respect of the payment of any amount
due to the Company by charging the same to the relevant credit cards of the cardholder which is authorised herein. Any refundable premium will be
paid to the policyholder of the relevant policy only. The cardholder shall seek recovery from the aforesaid policyholder only in the case of refund,
and it will not contest the refunded premium. In the event of any proven fraud, the Company shall have the sole discretion to determine the manner in
which the payment shall be made and the person to whom the refund shall be made.
5. For recurrent deduction of Renewal Premiums and Future Premiums for Life Policy, the premiums will be charged to the credit card on the premium due
date.
6. For recurrent deduction of Renewal Premiums and Future Premiums for Accident and Health Policy, the premiums will be charged to the credit card on
the 11th or 26th of the month.
7. For ad-hoc deduction of Renewal Premiums for Life Policy / Accident and Health Policy, the premium will be charged within 2 working days upon receipt
of the credit card authorisation form.
8. This credit card authorisation will remain in force until terminated by the policyholder by giving at least one month’s notice in writing to the Company. 9.
The cardholder and the policyholder shall accept full responsibility for all transactions arising from the use of the relevant credit cards in payment of
premium(s).
10. The Company shall not be held responsible for any claims, losses, damages, costs and expenses arising from the successful processing of the debit
or the unsuccessful processing of the debit due to exceeding credit limit, malfunction of system, electricity failure and any other factors beyond the
control of the Company.
11. The Company may at its absolute discretion at any time terminate this credit card payment arrangement without assigning any reason by giving the
policyholder one month’s notice in writing.
12. The Company reserves the right to change any terms and conditions set out herein at any time or from time to time when circumstances warrant
without prior written notice to the cardholder and the policyholder.
13. The policyholder and the cardholder hereby agree to indemnify and keep the Company indemnified against any claims, losses, damages, costs and
expenses which the Company may suffer or incur arising from the cardholder’s and policyholder’s authorisation to debit the cardholder’s and/or
policyholder’s credit card accounts.
14. Premium payments that are due in respect of the relevant policy will be considered as paid only upon successful processing of the debit by the
Company. No official receipts will be issued.
15. Should payment not be successfully effected pursuant to this authorisation for any reason, the Company shall under no circumstances be held
responsible or liable in any manner whatsoever including any subsequent expiry of the policies due to late or non-payment of premiums.
16. The Proposer/Cardholder will need to bear all charges (administration fees, foreign exchange charges, etc) imposed by the bank.

The Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G) CS243 Aug 2024 1 Pickering Street #01-01 Great Eastern Centre Singapore 048659
Tel: 1800-248 2888 (Local), (65) 6248 2888 (Overseas)
Email: [email protected] Website: greateasternlife.com
Email: [email protected] Website: greateasternlife.com