CREDIT CARD SERVICE

ENROLMENT FORM

PERKHIDMATAN KAD KREDIT

BORANG PERMOHONAN

Prudential BSN Takaful Berhad (740651) Level 8A, Menara Prudential, No. 10, Jalan Sultan Ismail, 50250 Kuala Lumpur. P.O.Box 10073, 50704, Kuala Lumpur Customer Service Hotline: 603-2053 7188 Fax-2072 6188 E-mail: [email protected] Yes ! I wish to pay my Family Takaful contribution through credit card service and agree to abide by the Terms & Conditions as specified overleaf. Ya ! Saya ingin membuat pembayaran caruman melalui perkhidmatan kad kredit dan mematuhi Syarat-syarat & Terma seperti yang tertera di belakang lampiran.

PERSONAL DETAILS

BUTIR-BUTIR PERIBADI

This Service is applicable for VISA/ MASTERCARD holders only. Please complete this form in CAPITAL LETTERS using DARK BLACK ink only. Perkidmatan ini hanya untuk pemegang VISA/ MASTERCARD sahaja. Sila isi dengan menggunakan HURUF BESAR dan dakwat HITAM GELAP sahaja. Please be advised that no receipt will be issued for contribution paid through credit card. Adalah dimaklumkan bahawa tiada sebarang resit yang akan dikeluarkan untuk pembayaran melalui kad kredit ini. Cardmember's Name (as shown on NRIC)

Nama Pemegang Kad (seperti dalam Kad Pengenalan) : Address

Alamat : Old NRIC Number

New NRIC Number

Nombor Kad Pengenalan Lama:

Nombor Kad Pengenalan Baru:

Residence Telephone No

Office No

Handphone No

Nombor Telefon Kediaman:

Nombor Pejabat:

Telefon Bimbit

Card Expiry Date

Card Account Number

Numbor Akaun Kad

:

:

Tarikh Kad Tamat : M

Pengeluar Kad

M /

Y

Y

Card issuing Country : Malaysia/Only Negara Pengeluar kad: Malaysia/Sahaja

Card Issuing Bank

:

CONTRIBUTION PAYMENT INSTRUCTION

ARAHAN PEMBAYARAN CARUMAN

I hereby authorise the bank appointed by PRUDENTIAL BSN TAKAFUL BERHAD (PruBSN) to debit my credit card account for the contribution of the proposals/ certificates stated below: Dengan ini, saya membenarkan bank yang dicadangkan oleh PRUDENTIAL BSN TAKAFUL BERHAD (PruBSN) untuk mendebitkan akaun kad kredit saya bagi caruman cadangan/sijil di bawah : Signature of Cardmember (as in card) Tandatangan oleh Pemegang kad (spt dalam kad):

Name of Person Covered Nama Orang yang Dilindungi

Relationship Hubungan

Proposal No No Cadangan

Certificate No No. Sijil

Date / Tarikh:

FOR OFFICE USE / UNTUK KEGUNAAN PEJABAT

FOR AGENT USE / UNTUK KEGUNAAN EJEN

Agent's Code Kod Ejen:

Section / Bahagian

Agent's Name Nama Ejen Telephone no No telefon : New proposal contribution amount Amaun caruman cadangan baru : RM

Form ID

60801003

Remarks / Catatan

TERMS & CONDITIONS / SYARAT-SYARAT & TERMA 1.

The contribution amount will be automatically debited to the applicant's Credit Card Account upon the transaction being successfully processed by the relevant Financial Institution with which the applicant holds a Credit Card Account. Jumlah caruman akan didebitkan secara automatik daripada Akaun Kad Kredit selepas transaksi berjaya dilaksanakan oleh pihak Bank yang mengeluarkan Kad Kredit kepada pemohon.

2.

Contribution under the Credit Card Service is charged at Cash/Cheque rate. If the applicant's current contribution is under Banker's Order rate, the applicant's authorisation to deduct contribution payments from Credit Card also authorises PruBSN to change the applicant's contribution to Cash/Cheque rate. Bayaran caruman melalui Perkhidmatan Kad Kredit adalah pada kadar Tunai/Cek. Jiku cara pembayaran caruman pemohon yang terkini adalah melalui potongan Bank, maka dengan membuat pemotongan caruman daripada Kad Kredit akan membenarkan PruBSN mengubah kadar caruman tersebut kepada kadar Tunai/Cek.

3.

For new proposal payment, contribution deduction will commence upon receipt of the proposal form and Credit Card Service enrolment form. Should this amount be insufficient, the applicant hereby authorises PruBSN to deduct the balance of contribution required under the proposal. All payments will be held under the proposal until the certificate commences and no interest shall be payable. Untuk pembayaran bagi cadangan yang baru, potongan caruman akan bermula dari tarikh penerimaan borang cadangan dan borang pemohonan Perkhidmatan Kad Kredit. Sekiranya jumlah tersebut tidak mencukupi, dengan ini pemohon memberi kuasa kepada PruBSN untuk memotong baki caruman yang dikehendaki bagi cadangan tersebut. Semua pembayaran akan disimpan sebagai kredit dalam cadangan sehingga sijil bermula tanpa dikenakan kadar faedah kepada pemohon.

4.

PruBSN is under no obligation to honour any Credit Card debit instruction unless, the credit card account is valid and in goodstanding at the time of effecting payment PruBSN tidak akan melaksanakan transaksi dibawah Perkhidmatan Kad Kredit ini melainkan Akaun Kad Kredit adalah sah dan dalam keadaan baik sewaktu pembayaran hendak dilakukan.

5.

This instruction will remain effective for the protection of PruBSN notwithstanding death and incapacity on the part of the applicant unless the Company is notified to cease further debits. Arahan ini akan terus berkuatkuasa bagi kepentingan PruBSN selagi tidak diberitahu untuk menamatkan pendebitannya walaupun berlaku kematian dan ketidakupayaan pada pihak pemohon.

6.

In the event that any alterations and cancellations of this authorisation are to be effected, the applicant shall ensure that PruBSN is notified at least one month before the next payment date. Pemohon perlu memastikan bahawa PruBSN diberitahu mengenai penukaran atau pembatalan yang dibuat oleh pemohon sekurang-kurangnya sebulan sebelum pembayaran caruman yang seterusnya dilaksanakan.

7.

The applicant must inform PruBSN in writing of changes to the Credit Card Account numbers, including new account numbers issued under "lost card" or" conversion", termination or cancellation of Credit Card Accounts and changes or renewal of expiry date. Pemohon perlu memberitahii PruBSN secara bertulis mengenai penukaran nombor Akaun Kad Kredit termasuklah nombor Akaun Kad Kredit yang baru disebabkan oleh " kad hilang" atau " penukaran", penamatan atau pembatalan Akaun Kad Kredit dan penukaran atau pembaharuan tarikh tamat kad.

8.

The applicant agrees that PruBSN shall be entitled to impose charges deemed appropriate for providing the service mentioned hereunder with prior notice to the applicant. Pemohon bersetuju bahawa PruBSN berhak untuk mengenakan bayaran yang sesuai bagi penyediaan perkhidmatan yang dinyatakan dengan memberi notis terlebih dahulu kepada pemohon.

9.

PruBSN reserves the right to change the Terms and Conditions and determine the arrangements for the service provided hereunder at its discretion. PruBSN berhak meminda atau menambah kandungan Syarat-syarat dan Terma dan menentukan perkara yang berhubung dengan perkhidinatan ini.

10.

PruBSN shall not be responsible or liable for any claim, loss, damage, cost and expenses arising from the unsuccessful processing of the charging of contribution amounts or remittance for any reason whatsoever, including but not limited to malfunction of system, electricity failure, inaccurate or insufficient information being supplied by the applicant. PruBSN tidak akan bertanggungjawab atau dipersalahkan keatas apa-apa tuntutan, kehilangan, kos dan perbelanjaan yang timbul daripada proses pendebitan yang tidak berjaya terhadap bayaran caruman yang dikenakan atau pemindahan wang untuk apa-apa sebab sekalipun, tetapi tidak terhad kepada kerosakan sistem, putus bekalan elektrik, menerima maklumat yang tidak tepat atau tidak lengkap daripada pemohon.

11.

PruBSN may at any time and from time to time without prior notice withdraw from providing the service mentioned hereunder at any time without assigning any reasons therefore and shall not be held liable for any loss or damage which may be suffered by the applicant as a result of such action by PruBSN PruBSN boleh menarik diri daripada memberikan perkhidmatan ini pada bila-bila masa tanpa memberikan sebarang notis dan dengan ini tidak akan dipertanggungjawabkan untuk sebarang kehilangan atau kerosakan yang mungkin ditanggung oleh pemohon ke atas tindakan PruBSN

PBTB Credit Card Form.pdf

Page 1 of 2. Form ID 60801003. CREDIT CARD. SERVICE. PERKHIDMATAN KAD KREDIT. BUTIR-BUTIR PERIBADI. CONTRIBUTION PAYMENT ...

73KB Sizes 10 Downloads 176 Views

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