Prudential Assurance Company Singapore (Pte) Limited (Reg. No.: 199002477Z) Postal Address: Robinson Road P.O. Box 492, Singapore 900942 Website: www.prudential.com.sg Part of Prudential Corporation plc

L5CCRN

P01112017

Important Notes 1. Not applicable to Corporate / Debit Cards / American Express / Diners Club / JCB / UnionPay / Non-Singapore issued Credit Cards. 2. Credit Card payments are accepted only for policies with existing premium payment methods by cash, cheque or GIRO and are expressed in

Singapore Dollars.3. Credit Card may not be used for payment of premiums for:

(i) Single premium policies, recurring single premium policies, US Dollar policies and policies purchased under the CPF Investment Scheme and Supplementary Retirement Scheme.

(ii) PruShield premiums funded by Medisave and where the premium amounts are within the Medisave withdrawal limits.4. Upon the approval of this application, any premium(s) in arrears (up to a maximum of 2 months' arrears), together with the current month's premium will

be charged to the Cardholder’s Credit Card. Future premium(s) amount will be charged on the due date of the premium(s) and the Cardholder’s CreditCard statement will show the amount deducted. No Premium Notices and Official Receipts will be issued. The relevant entries in Cardholder’s Credit Card statement will be recognised as evidence of payments.

5. If premium payments are made monthly and there is any premium which remains unpaid within the period stated in the terms and conditions of policies indicated herein in which premium payments are allowed, there will be an additional attempt to charge the premium to the Cardholder’s Credit Card oneither the monthly premium due date or 15 days after.

6. If Prudential is unable to charge the premium to the Credit Card on the premium due date, another attempt shall be made after 15 days. 7. If an attempt to charge the Credit Card falls on a Saturday, Sunday or a Public Holiday, it will take place on the next working day.8. If the policy transactions are not taken up subsequently, premiums paid through this application will be reversed back to the Credit Card account. 9. All authorisations referred in this application shall remain in force until receipt of the Policyowner or Cardholder’s revocation to Prudential.10. Each of the specific authorisations set out in this application shall be in addition to any other consent and/or disclosure that the Policyowner or

Cardholder may have provided to Prudential and the Bank.11. If the Cardholder is not the Policyowner, he/she has no right under the Contract (Rights of Third Parties) Act, Cap 53B, to enforce any of the terms

and conditions of that policy.

By completing this Application Form, I am instructing and authorising: (i) Prudential and the Bank to automatically debit my Credit Card account to pay for my own and/or my Family Member's policy/policies. "Family

Members" shall mean spouse, children, parents, parents-in-law, brothers and sisters;(ii) Prudential and the Bank to charge any additional premium arising from a change of the amount that is required to be paid as premium (including but not

limited to an increase or inclusion of benefits or from a reinstatement with or without special terms and conditions);(iii) Prudential and the Bank to change the expiry date of the Credit Card, so long as there is no change in the name of the Cardholder and the Credit Card

number;(iv) the Bank to notify Prudential of any change in my Credit Card account details. In the event that any new Credit Card account is issued to me in addition

to/as replacement of/in lieu of the Credit Card account as indicated in this Application Form, these terms and conditions shall be deemed to apply to each such new Credit Card account and I hereby irrevocably authorise the Bank and Prudential to debit each new Credit Card account for the payment of all permitted regular premiums in relation to the policies indicated herein;

(v) and consenting to Prudential to use, disclose any information collected and/or held (whether contained in this form or otherwise obtained) to itsassociated individuals/organisations and/or independent third parties, within or outside Singapore, with regard to any matters pertaining to this form/policies; and

(vi) should payment not be successfully effected pursuant to this authorisation for any reason, Prudential 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.

I have read the terms and conditions set out in this Application Form and marked "Important Notes", and I agree to be bound by the said terms and conditions.

Name of Cardholder Contact No. (Mobile/Tel)

-

NRIC / Passport No. of Cardholder

(Country Code)

Credit Card No. - - -

Credit Card Issuing Bank (“Bank”), pls tick one Expiry Date (MM/YY) SCB UOB CITIBANK /

DBS/POSB MAYBANK OCBC

Policy No. Particulars required if Cardholder is not Policyowner

Name of Policyowner NRIC No.

Total No. of policies

PruCustomer Line: 1800 333 0333 (Local)+65 6333 0333 (Overseas)

APPLICATION FOR REGULAR PREMIUM PAYMENT BY CREDIT CARD

Section A Please complete this form and return to Prudential Assurance Company Singapore (Pte) Limited

Cardholder's Signature Date (dd-mm-yyyy)

Name on Credit Card

BUSINESS REPLY SERVICE PERMIT NO. 00364

Postage will be paid by

addressee. For posting in

Singapore only.

PRUDENTIAL ASSURANCE COMPANY SINGAPORE (PTE) LIMITED Robinson Road P.O. Box 492

Singapore 900942

1. Fold along the dotted lines.2. Fold and insert your document into this prepaid business reply folder.

3. Seal along the edges of this prepaid business reply folder with clear tape (do not staple).4. Drop your sealed prepaid business reply folder into your nearest post box.