Application/Policy No. / No.

Permohonan/Polisi

DIRECT CREDIT FORM (E-PAYMENT)

BORANG PINDAHAN TERUS (E-BAYARAN)
Enrolment for Payments via Direct Credit into Bank Account (E-Payment).
Permohonan untuk bayaran melalui Pindahan Terus ke Akaun Bank (E-Bayaran).
Payments shall include investment payments, surrender payment, maturity payment, partial withdrawal, claims payment, refund, cancellation and
others (where applicable). / Pembayaran termasuk bayaran pelaburan, pembayaran balik, bayaran matang, pengeluaran separa, pembayaran
tuntutan, bayaran balik, pembatalan dan lain-lain (jika berkenaan)
This form is to be filled by the Proposed Insured /Insured (if no owner) or Proposed/Policy Owner in BLOCK LETTERS. / Borang ini perlu diisi oleh
Hayat Dicadangkan/Hayat Diinsuranskan (sekiranya tiada pemunya polisi) atau Pemunya Dicadangkan/Pemunya Polisi menggunakan HURUF
BESAR.

Bank Name / Nama Bank:

Bank Account Number / Nombor Akaun Bank:

Bank Account Holder’s Name / Nama Pemegang Akaun Bank:

NRIC Identity No. / No Pengenalan NRIC:

Police/Army/Other Identity No. / No. Polis/ Tentera/Lain Pengenalan:

Date / Tarikh
Type of Account / Jenis Akaun:
– –
Savings Account / Akaun Simpanan DD/HH MM/BB YY/TT
Indvidual Joint*
Individu Bersama* Signature of the Bank Account Holder
Tandatangan Pemegang Akaun Bank
Current Account / Akaun Semasa
Indvidual Joint*
Individu Bersama*

Copy of account passbook/bank statement/bank slip is attached

Salinan buku akaun bank/penyata bank/slip bank di lampirkan
* Applicable to those account with instruction for either party to sign only.
Untuk Akaun dengan arahan tandatangan oleh salah satu pihak sahaja.

NOTICE/NOTIS :-
1. The account holder must be the Proposed Insured/Insured or Proposed/Policy Owner of this policy. / Pemegang akaun adalah Hayat
Dicadangkan/Diinsuranskan/Pemunya Dicadangkan/Pemunya Polisi bagi polisi ini.
2. The E-Payment facility is only applicable for bank accounts maintained with one of the financial institutions offering MEPS Inter-Bank GIRO (IBG)
service. / Kemudahan E-Bayaran hanya boleh digunakan untuk akaun bank yang dikekalkan dengan salah satu daripada institusi kewangan yang
menawarkan perkhidmatan MEPS Inter-Bank GIRO (IBG).
3. Proposed Insured/Insured/Proposed/Policy Owner is to furnish AXA AFFIN Life Insurance Berhad a copy of bank account passbook or bank
statement or bank slip for purposes of verifying the account holder’s bank account number. If copy of bank account passbook or bank statement
or bank slip is not furnished, the Proposed Insured/Insured/Proposed/Policy Owner is deemed to have confirm the account details given in this
form as valid and accurate. / Hayat Dicadangkan/Diinsuranskan/Pemunya Dicadangkan/Pemunya Polisi perlu mengemukakan AXA AFFIN Life
Insurance Berhad satu salinan buku akaun bank atau penyata bank atau slip bank untuk tujuan pengesahan nombor bank akaun pemegang akaun.
Jika salinan akaun buku bank atau penyata bank atau slip bank tidak dikemukakan, Hayat Dicadangkan/Diinsuranskan/Pemunya
Dicadangkan/Pemunya Polisi dianggap telah mengesahkan butir-butir akaun di dalam borang ini sebagai sah dan tepat.
4. AXA AFFIN Life Insurance Berhad shall not be liable or responsible for any loss which may arise solely by reason of error, mistake or fraud regarding
this information. / AXA AFFIN Life Insurance Berhad tidak akan bertanggungjawab bagi apa-apa kerugian yang mungkin timbul di atas kesilapan,
kesalahan atau penipuan mengenai maklumat ini.
5. All payments due shall be paid into the above account unless the account holder notify AXA AFFIN Life Insurance Berhad otherwise in writing. /
Semua bayaran yang sewarjarnya akan dibayar ke dalam akaun di atas melainkan jika pemegang akaun memberitahu AXA AFFIN Life Insurance
Berhad sebaliknya secara bertulis.

AXA AFFIN Life Insurance Berhad (723739W)

8th Floor, Chulan Tower, No.3 Jalan Conlay, 50450 Kuala Lumpur
Telephone: 03-2117 6688 Fax: 03-2117 3698 1 300 88 1616 www.axa.com.my 1 of 1