CREDIT AND
DEBIT CARD
MANDATEWHO IS THIS FORM FOR?
This form is for policyholders whowish to pay their policy premiumsby credit or debit card. You canalso use this form to tell us abouta new card if your old one is about
to expire. Depending on the typeof 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
In order to comply with the Isleof Man Insurance (Anti-MoneyLaundering Regulations) 2008, wemay require additional source ofwealth evidence subject to where
the bank that issued your credit
or debit card is registered. For
further information about country
tiers please refer to our sourceof wealth information document
available online at www.rl360.com/
sourceofwealth.pdf.
If you need help completing thisform please contact our Customer
Services Team on +44 (0)1624
681682 or alternatively you canemail csc@rl360.com.

WHEN YOU HAVE COMPLETEDTHIS FORM

CREDIT CARD
PRE‑AUTHORISATION

Please send the original signed
instruction by post to: Premiums
Team, RL360, International House,Cooil Road, Douglas, Isle of Man,IM2 2SP, British Isles.

Pre-authorisation is the processof pre-approving payments withyour card provider. We carry out
this process to make sure thatthe card’s details are correct
and working properly prior tocollecting your premium.

IMPORTANTWe are only able to accept credit ordebit cards where the card displays
one of the logos above and isprefixed with a ‘3’, a ‘4’ or a ‘5’.
Please note that if you own aQuantum Malaysia policy, you will
not be able to pay premiums using
American Express. If you own aLifePlan Lebanon policy, you will
not be able to pay premiums using
American Express or JCB.
We regret that we cannot accept
payments from Rand or Zimbabwe
dollar denominated cards.
The maximum amount that canbe collected by credit card is
GBP99,999.99 (or currency
equivalent) per premium.
Please make sure you allow 5
working days for your request tobe processed.
We will also require 5 working days
to process any cancellations oramendments to your card details.

1This process will create a
pre‑authorisation on your credit
card for one unit of the currency
you pay your premiums in i.e.
GBP1.00/USD1.00/EUR1.00 etc.
This amount may not appear on
your credit card statement, butwill affect the card balance orspending limit until your card
provider removes it.
If you have opted to receive text
messages from your card provider,
you may get a confirmation text
for this transaction.

CREDIT CARD MANDATERL360 policy number
Policyholder name(s)I authorise you, until further notice in writing, to collect payments as detailed below:
Premium currency

Sterling (GBP)

US dollar (USD)

Australian dollar (AUD)Euro (EUR)

Hong Kong dollar (HKD)

Swiss franc (CHF)
Japanese yen (JPY)

Premium amountin figuresPremium amountin words
Premium frequency

Monthly

Quarterly

Half-yearlyYearlyPremiumcommencement
date (dd/mm/yyyy)
Card type

Mastercard/Eurocard

Visa		JCB		

American Express** The amount we collect from your card will be 1% higher than your premium to cover additional charges
applied by American Express.
(name of bank)

Card issued byCountry of card issue
Cardholder’s name(s)(must be apolicyholder)
Cardholder’s address(as held by the cardissuer)-Card numberExpiry date (mm–yy)---

I understand that RL360 Insurance Company Limited (RL360) will advise me of the amount to be paid and the dates on which
payment is due and that RL360 may only change these after giving me prior notice.
I understand that this authority in favour of RL360 will remain in force until such time as I cancel it in writing.
Signature ofcardholder(s)Date (dd/mm/yyyy)		

RL360 Insurance Company Limited. Registered Office: 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.

RL166g 02/182