Who is this form for?
This form is for policyholders who wish to set up a direct debit to pay their policy premiums. The Direct Debit payment option is
only available where the account is denominated in pounds sterling (GBP) and is based in the UK or Channel Islands.
Depending on the type of policy you hold this payment option may not be available for specific payment frequencies, please
check your policy literature or contact us before completing.
Completing this form
Please make sure that the direct debit comes from a policyholder’s own bank account.
You must complete this form in full, making sure that all policyholders, trustees or authorised signatories sign.
Where applicable, please ensure that the authorised signatory list(s) that we hold for your policy are up-to-date before
submitting instructions. Where authorised signatories have changed and we are unable to match those on this form with our
records, this will cause a delay. We may also request further information for the purposes of Anti-Money Laundering.
If you need help completing this form please contact our Customer Services Team on +44 (0)1624 681682 or alternatively you
can email csc@rl360.com.
When you have completed this form
Please send the completed instruction to premiums@rl360.com or alternatively you can post this to: Premiums Team, RL360,
International House, Cooil Road, Douglas, Isle of Man, IM2 2SP, British Isles.
Any changes to your premiums, including as a result of automatic premium escalation, will be applied without the need for a
further instruction.
Privacy policy
Our full privacy policy can be viewed at www.rl360.com/privacy or can be obtained by requesting a copy from our Data
Protection Ocer.
RL167f 01/21
RL360 Insurance Company Limited. Registered Oce: International House, Cooil Road, Douglas,
Isle of Man, IM2 2SP, British Isles. Registered in the Isle of Man number 053002C. RL360
Insurance Company Limited is authorised by the Isle of Man Financial Services Authority.
Service User Number
2 7 0 0 5 0
Name and full postal address of your bank or building society branch
To the manager
Bank/Building Society
Bank address
Name(s) of account
Bank sort code
Account number
This Direct Debit Instruction relates to my policy number, reference:
Instruction to your bank or building society
Please pay RL360 Insurance Company Limited Direct Debits from the account detailed in this instruction, subject to the
safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with RL360 Insurance Company
Limited and, if so, details will be passed electronically to my bank/building society.
Account holder/Authorised Signatory 1 Account holder
/Authorised Signatory 2
Full name
Current residential address
and postcode (in full)
Date (dd/mm/yyyy)
Banks and building societies may not accept Direct Debit instructions from some types of account
The Direct Debit Guarantee
This Guarantee is oered by all banks and building societies that accept instructions to pay Direct Debits
If there are any changes to the amount, date or frequency of your Direct Debit, RL360 Insurance Company Limited will notify you 14
working days in advance of your account being debited or as otherwise agreed. If you request RL360 Insurance Company Limited to
collect a payment, confirmation of the amount and date will be given to you at the time of the request
If an error is made in the payment of your Direct Debit by RL360 Insurance Company Limited or your bank or building society
you are entitled to a full and immediate refund of the amount paid from your bank or building society – If you receive a refund
you are not entitled to, you must pay it back when RL360 Insurance Company Limited asks you to.
You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be
required. Please also notify us.
This guarantee should be detached and retained by the payer.