Payment form

Direct Charge Authority
This form may be used in conjunction with regular premium policies and supersedes any previous instructions held.
Please do not complete this form if you intend emailing (or scanning and emailing) this form back to us. We can only accept thisform via post or fax. Details can be accepted electronically via our secure website at www.fpinternational.com/creditcard
Credit Card payments can only be accepted in USD, GBP, SGD, HKD or EUR.

Please use BLOCK CAPITALS
To:	Friends Provident International Limited
Royal Court, Castletown, Isle of Man, British Isles, IM9 1RA. Telephone: +44(0) 1624 821212. Fax: +44(0) 1624 821284.

Your details
I authorise you to debit myMastercard

VISA Credit Card 8MonthYear

Name of issuing company or bank
Country of issue
Credit Card Number
Credit Card expiry date 1

Figureswith the sum of 3

Words
Currency
in respect of premiums for my Policy Number
collected on the 4ofand on the same day until further noticeor cancelled in writing

MonthlyMonth
QuaterlyHalf-yearly

Name on Credit Card
Address of Credit Card Holder(as held by the Card Provider)

Postcode
Telephone number(daytime including country and area code)
Email address
Continued overleaf

CountryYearYearly

Your details (continued)
Signature

Date

Important information
1.	When your current Credit Card expires or is replaced, we will require you to complete a new Direct Charge Authority form.
Alternatively, you can update your Credit Card details online at www.friendsprovident.co.uk/creditcard
2.	When your Credit Card payment is first set-up certain checks will be administered, including a pre-authorisation check. A nominal
amount may show on your account, but the pre-authorisation is not a charge and no money will be deducted from your account.
3.	Where premiums are paid by Credit Card there will be a handling charge of between 1% and 1.95% (depending on residency) of
each premium paid. The handling charge will be collected in addition to the total premium amount meaning we will collect the total
premium amount plus the handling charge from your Credit Card. The handling charge will be used to cover the charges imposed bythe Credit Card issuing company.
4.	The premium collection date is up to six days prior to the due date on the contract, and varies to take into account seasonal andbank holidays.
5.	If you amend your premium, a new Direct Charge Authority form will need to be completed and returned to us.
6. 	If a payment is declined, we will automatically inform your Adviser by fax and request a duplicate payment the following month.
This will apply to consecutive months if the contract remains in arrears. No more than two premiums should be collected eachmonth until the premiums are up to date.
7. 	Please note that some Credit Cards cannot be used outside their country of issue and therefore we strongly recommend that you
contact your card issuer to ensure your card can be used in this instance.
8. Please note that Debit Cards cannot be accepted for premium payments.
9. Please note we cannot accept this form via email.
10. If you wish to cancel the Credit Card, please contact us via email at customerservices@fpiom.com or by telephone +44(0) 1624 821212.

Friends Provident International Limited: Registered and Head Office: Royal Court, Castletown, Isle of Man, British Isles, IM9 1RA.
Telephone: +44 (0)1624 821212 | Fax: +44 (0)1624 824405 | Website: www.fpinternational.com. Isle of Man incorporated company number11494C. Authorised and regulated by the Isle of Man Financial Services Authority. Provider of life assurance and investment products.
Authorised by the Prudential Regulation Authority. Subject to regulation by the Financial Conduct Authority and limited regulation by
the Prudential Regulation Authority. Details about the extent of our regulation by the Prudential Regulation Authority are available
from us on request. Singapore branch: 4 Shenton Way, #11-04/06 SGX Centre 2, Singapore 068807. Telephone: +65 6320 1088 |Fax: +65 6327 4020 | Website: www.fpinternational.sg. Registered in Singapore No. T06FC6835J. Licensed by the Monetary Authorityof Singapore to conduct life insurance business in Singapore. Member of the Life Insurance Association of Singapore. Member of theSingapore Financial Dispute Resolution Scheme. Hong Kong branch: 803, 8/F., One Kowloon, No.1 Wang Yuen Street, Kowloon Bay,Hong Kong. Telephone: +852 2524 2027 | Fax: +852 2868 4983 | Website: www.fpinternational.com.hk. Authorised by the Insurance
Authority of Hong Kong to conduct long-term insurance business in Hong Kong. Dubai branch: PO Box 215113, Emaar Square, Building 6,Floor 5, Dubai, United Arab Emirates. Telephone: +9714 436 2800 | Fax: +9714 438 0144 | Website: www.fpinternational.ae. Registered inthe United Arab Emirates with the UAE Insurance Authority as an insurance company. Registration date, 18 April 2007 (Registration No. 76).
Registered with the Ministry of Economy as a foreign company to conduct life assurance and funds accumulation operations (Registration
No. 2013). Friends Provident International is a registered trademark and trading name of Friends Provident International Limited.
XIM/DCA 10.20 (13331)