Fillable TELEGRAPHIC TRANSFER INSTRUCTION - PROTECTED LIFESTYLE LEBANON SERVICING (RL360)

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TELEGRAPHIC TRANSFER INSTRUCTION - PROTECTED LIFESTYLE LEBANON SERVICING (RL360)

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1
WHO IS THIS FORM FOR?
This form is for holders of Protected Lifestyle Lebanon policies who wish to send a premium payment to us by telegraphic transfer.
COMPLETING THIS FORM
Please instruct your bank that you would like to debit an amount of money from your account in relation to your policy. You must
complete this section 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.
Important
Some banking institutions may deduct charges for processing international payments. Please check with your bank if any
charges will apply prior to transferring your premium to us. If they do, please make sure that the amount your bank transfers
to us is enough, so that the remaining amount received by RL360 is at least equal to your premium.
If you need help completing this form please contact our Lebanon Oce on +961 (1) 202 183/4 or alternatively you can email
lebanonservice@rl360.com.
WHEN YOU HAVE COMPLETED THIS FORM
Please send the original signed instruction to your bank and a copy by post to: RL360, Burj Al Ghazal, 8th Floor, Fouad Chehab
Highway, Ashrafieh, Tabaris, Lebanon.
Or alternatively you can fax a copy to us on +961 (1) 202 159.
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.
TELEGRAPHIC TRANSFER
INSTRUCTION -
PROTECTED LIFESTYLE
LEBANON
SERVICING
RL180e 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.
2
You must complete this section in full, making sure that all policyholders, trustees or authorised signatories sign.
To the manager
Bank/Building Society
Bank address
Policy number
(please use this number as the reference for payments)
Policyholder name(s)
Please debit the payment amount, plus any transfer charges from my account below:
Currency
US dollars (USD)
Payment amount in figures
Payment amount in words
Payment commencement
until further notice.
date (dd/mm/yyyy)
Name(s) of account
holder(s)
Branch Swift Code
OR Bank Sort Code
- -
(for all non–GBP and International payments) (for UK GBP payments only)
Swift Code must be either 8 or 11 digits
IBAN
OR Account number
(all non–GBP accounts) (GBP UK Bank only)
Currency IBAN Swift code Bank name Account name
USD LB48 0007 0000 0050 2271 0131 BBMELBBX HSBC RL360
Bank address: HSBC Building, PO Box 11-1380, Minet el-Hosn, Beirut, Lebanon
Policyholder/Trustee/Authorised Signatory 1
Policyholder/Trustee/Authorised Signatory 2
Signed
Full name
Current residential address
and postcode (in full)
Date (dd/mm/yyyy)
Trustee/Authorised Signatory 3 Trustee/Authorised Signatory 4
Signed
Full name
Current residential address
and postcode (in full)
Date (dd/mm/yyyy)
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TELEGRAPHIC TRANSFER INSTRUCTION - PROTECTED LIFESTYLE LEBANON SERVICING (RL360)

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Completed 21 June 2021

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