Name of Insured

Contact Number

Class of Insurance Motor Health Home Marine Travel Personal Accident Property & Casualty

Vehicle Number

Policy Type New Renewal Endorsement

Period of Insurance (From)

Period of Insurance (To)

Amount to be Debited

Payment Mode Full Payment Installment Plan (6 months) - 0% Interest Free * Installment Plan (12 months) - 0% Interest Free *

Bank OCBC DBS POSB UOB

* 0% Interest Free: Only for participating Banks and subject to their Card Agreement Terms & Conditions. Minimum premium of S$200 is required for OCBC and S$500 for DBS/POSB/UOB. The 0% interest free installment plan presented in this form is a facility offered by the Bank. Upon deduction of the premium via this installment scheme, you will receive an SMS notification from the Bank, stating the full premium charged to your credit card. The monthly installment amount and installment period will then be reflected in your monthly credit card statement.

Cardholder Name

State Relationship (where cardholder is not the Insured) Your security is our concern. If cardholder is not the Insured nor the insured's spouse, parent, parent-in-law, child or sibling, AXA insurance reserves the right to reject payment via credit card.

Credit Card Number

Expiry

CVV Number

- For Visa, MasterCard & Diners, CVV is the last 3-digit no. printed just above the signature panel in reverse italics on the back of your card.
- For AMEX, it is the 4-digit no. printed on the front of the card above the card number.

Cardholder's Signature

Contact Number