PRU LIFE INSURANCE CORPORATION OF U.K.
9/F Uptown Place Tower 1, 1 East 11th Drive, Uptown Bonifacio,
1634 Taguig City, Philippines
Customer helpdesk: (632) 683 9000, (632) 884 8484, (632) 887 LIFE
within Metro Manila, 1 800 10 PRULINK for domestic toll-free
Email: contact.us@prulifeuk.com.ph Website: www. prulifeuk.com.ph
Credit Card
Enrollment form
Last name First name M.I.
Billing option (Please check)
One-time payment Amount :
Recurring payment
(Required for monthly mode)
Policyowner:
Policy no.:
Primary Card Alternate card
Last name First name M.I.
Cardholder:
Relationship to Policyowner:
Contact nos.:
Card no.:
Expiry date:
Month Year
Bank issuer:
Cardholder declaration and authorization
I hereby declare under the penalty of perjury that the information provided above is true and correct.
I hereby also state that I have read and agreed to the terms and conditions stipulated at the back of this
form. By affixing my signature below, I hereby authorize Pru Life UK to charge the payments due for
the insurance application/policy number indicated above to my credit card account. I likewise confirm
that the payments herein charged to my credit card account are valid and accurate, despite the
absence of my signature in the sales slip or terminal receipt for such payments, I further waive the
requirement that Pru Life UK prepare, issue, submit or deliver to me a true and completed copy of the
sales slip or terminal receipt covering these payments.This authorization will be cancelled after five (5)
days from receipt by Pru Life UK of my written notice to cancel it.
Cardholder’s signature:
Effectivity date:
Policyowner’s signature:
(if other than the cardholder)
Visa
Mastercard
Last name First name M.I.
Cardholder:
Relationship to Policyowner:
Contact nos.:
Card no.:
Expiry date:
Month Year
Bank issuer:
Cardholder declaration and authorization
I hereby declare under the penalty of perjury that the information provided above is true and correct.
I hereby also state that I have read and agreed to the terms and conditions stipulated at the back of this
form. By affixing my signature below, I hereby authorize Pru Life UK to charge the payments due for
the insurance application/policy number indicated above to my credit card account. I likewise confirm
that the payments herein charged to my credit card account are valid and accurate, despite the
absence of my signature in the sales slip or terminal receipt for such payments, I further waive the
requirement that Pru Life UK prepare, issue, submit or deliver to me a true and completed copy of the
sales slip or terminal receipt covering these payments.This authorization will be cancelled after five (5)
days from receipt by Pru Life UK of my written notice to cancel it.
Cardholder’s signature:
Effectivity date:
Policyowner’s signature:
(if other than the cardholder)
Visa
Mastercard
