PAYMENT AUTHORIZATION FORM

Entity: Insurance Takaful You are our: Customer Agent

Name of Card Member

Agent Account No. FLAS Payment No.

Policy/ Certificate No. Vehicle Registration No.

Premium/ Contribution Amount (RM)

Contact No. ___

Payment Details Listing (If any) Yes No

Credit Card Debit Card Issuing Bank

Please charge my Visa/ Master Cards/ AMEX as I have indicated below (Please tick one):

Credit Card No.
*Debit Card No.
Applicable for Customer of Etiqa Oneline ONLY
Card Expiry Date (MM/YY) /
I hereby authorize Etiqa Insurance Berhad (EIB)/ Etiqa Takaful Berhad (ETB) to charge my premium/ contribution with
EIB/ ETB to my VISA/ MASTER/ AMEX account. I understand that if EIB/ ETB failed to charge to my VISA/ MASTER/
AMEX account for whatever reason, I will be notified by EIB/ ETB and will make necessary outstanding payment of
premium/ contribution in other mode of payment within the grace period stipulated in the provision of Policy/
Certificate. I have the option to cancel this payment instruction by giving thirty (30) days to EIB/ ETB.

*Signature of Card Holder Date:

Signature must correspond with card
Payment Details Listing (if any)
Policy/ Vehicle Registration Premium/ Contribution
No. Insured/ Participant Name
Certificate No. No. (if any) Amount (RM)