Download - Prudential Singapore

PruCustomer Line : 1800 - 333 0 333
APPLICATION FOR CHANGE OF OWNER/PAYER
IMPORTANT NOTES
1. If you have an existing PruShield Extra/Extra Lite policy, please note that the Owner/Payer for PruShield and PruShield
Extra/Extra Lite policies will be changed at the same time.
2. If the new payer is a child/ward below age 17, the owner of the policy will not be changed. Please also submit the
Application Form for Change of Back-Up Payer for this request.
3. Secondary billing payment refers to the amount in excess of the Medisave withdrawal limit or plans payable by cash.
4. Please submit the Application For Regular Premium Payment By Credit Card OR Application For Premium Payment
by Interbank GIRO.
PruShield Policy No:
PruShield Extra/Extra Lite Policy No:
Name of Life Assured
:
NRIC/Birth Certificate No :
Name of Existing Owner/Payer :
NRIC/FIN/Passport No
2
Name of new Owner/Payer (as shown in NRIC)
:
Date of Birth (dd/mm/yyyy)
Please underline surname
NRIC No.
CPF / Medisave Account No.
Gender ()
Marital Status ()
Female
Male
Single
Residential Address
Married
Widowed
Divorced
Mailing Address (if different from residential address)
Country:
Postal code/Zip code:
Country:
Postal code/Zip code:
2
I, the new owner/payer , would like to pay the renewal premium for PruShield policy(ies) for ()
Myself
The Dependant(s) as stated below
Name of Dependant
NRIC/Birth
Certificate No.
Policy No. for
Prushield/ Prushield
Extra or Extra Lite
(if any)
Relationship
(must be spouse/
children/ parent/ legal
guardian)
Payment Options (if applicable):
3
4
I would like to make the secondary billing payment for my PruShield policy(ies) by Interbank GIRO/Credit Card
I would like to change my existing payment method for my PruShield Extra/Extra Lite policy(ies) / PruShield cash
4
plan policy(ies)
ID
L4MAJALT
May 2014
Prudential Assurance Company Singapore (Pte) Limited (Reg. No. 199002477Z)
Postal Address: Robinson Road P O Box 492 Singapore 900942
Tel: 1800 333 0 333 Fax: 6734 9555
Website: www.prudential.com.sg
Part of Prudential plc
PruCustomer Line : 1800 - 333 0 333
a)
I hereby declare that the above information is true and correct.
b)
I hereby authorise CPF Board to deduct from my Medisave Account, as specified by Prudential Assurance
Company Singapore (Pte) Ltd, the premium(s) due for the Live(s) to be covered as named under the policy(ies)
stated above, in accordance with the provision of the CPF Act (Chapter 36) and the rules and regulations made
thereunder and as amended from time to time and subject to all terms and conditions as may imposed by CPF
Board from time to time.
c)
I, the owner, on behalf of my child/ward (the "Life to be Assured") , hereby authorize the Central Provident Fund
Board (“the Board”) to deduct from my child/ward’s Medisave Account of the whole or part of the premium due for
this application as specified by Prudential Assurance Company Singapore (Pte) Ltd, in accordance with the
provisions of the Central Provident Fund Act (Chapter 36), and the rules and regulations made thereunder and as
amended from time to time and subject to all terms and conditions as may be imposed by the Board from time to
time. This is only applicable if the Life Assured is below 17 years old.
d)
This authorization shall continue in force until I have expressly revoked it by notice through Prudential Assurance
Company Singapore (Pte) Ltd to CPF Board.
e)
I understand that the existing payment method for PruShield and PruShield Extra/Extra Lite (if any) remains
unchanged.
f)
I understand that future premium(s) under the Prushield policy(ies) stated above will be deducted from my
Medisave Account (not applicable for PruShield cash plan).
g)
I authorise CPF Board to deduct the premium(s) due under the policy from my new Medisave Account should I be
given a new Medisave Account upon obtaining Singapore Permanent Residence status. (if applicable)
h)
I authorise CPF Board to disclose/seek information on a confidential basis to/from any insurer(s) such information
relating to:
i)
payment of premium(s) due under the policy(ies) stated above, including deduction of premiums from my
Medisave Account/new Medisave Account; and
j)
the making of refund(s) under the policy(ies) stated above, as CPF Board shall reasonably consider appropriate.
k)
I agree and authorise,
l)
Any medical source, insurance office or organisation to release to Prudential, and
m) Prudential to release to any medical source or insurance office, any relevant information concerning the Life to be
Assured at any time.
n)
I, the Life to be Assured named under this application, hereby consent to the transfer and disclosure, at any time
and without notice to me/us, of any medical information on me/us, in the Insurer’s or the CPFB’s possession,
between:
i.
the Insurer and the CPFB; and
ii.
the Insurer and other Insurers administering or operating an insurance scheme referred to in section
77(1)(k) of the Central Provident Fund Act (Chapter 36), for the purpose of assessing the insurability of
me/us and/or the making of a claim under the Central Provident Fund (MediShield Scheme) Regulations
(Rg. 20) or under an insurance scheme referred to in section 77(1)(k) of the Central Provident Fund Act
(Chapter 36).
o)
I agree to be bound by the terms and conditions of the Policy
Signature of Existing Owner/Payer
ID
Signature of New Owner/Payer or
Parent/Guardian of Payer
(applicable if new payer < age 17)
L4MAJALT
Date
May 2014
Prudential Assurance Company Singapore (Pte) Limited (Reg. No. 199002477Z)
Postal Address: Robinson Road P O Box 492 Singapore 900942
Tel: 1800 333 0 333 Fax: 6734 9555
Website: www.prudential.com.sg
Part of Prudential plc

Download Report