Direct Debit Authorisation 直接付款授權書 for payment in HK Dollars only 只適用於港幣付款

Declaration & Authorisation 聲明及授權

I/We HEREBY AUTHORISE my/our below named Bank to effect transfers from my/our account to that of the Company in accordance with such instructions
as my/our Bank may receive from the Company from time to time.
本人/吾等謹此授權本人/吾等以下所述的銀行，根據貴公司不時給予本人/吾等銀行之指示，由本人/吾等的戶口進行轉賬至貴公司的戶口。
I/We AGREE that my/our Bank shall not be obliged to ascertain whether or not notice of any such transfer has been given to me/us.
本人/吾等同意本人/吾等的銀行毋須查明上述的轉賬的通知有否送交本人/吾等。
I/We jointly and severally accept full responsibility for any overdraft (or increase in existing overdraft) on my/our account which may arise as a result of any
such transfer(s).
本人/吾等共同及各自承擔轉賬後可能出現的戶口透支 (或已存透支的增加) 的責任。
I/We AGREE to notify the Company of any change of bank account or cancellation of payment method and further agree that should there be insufficient funds in
my/our account to meet any transfer hereby authorised, my/our Bank shall be entitled, at its discretion, not to effect such transfer in which event the Bank may
make the usual charge and that it may cancel this authorisation at any time on one week's written notice.
本人/吾等同意會通知貴公司任何銀行戶口的變更或取消付款方式，亦同意如本人 /吾等的賬戶並無足夠款項支付該等授權轉賬，本人/吾等的銀行有權不予轉賬，且銀
行可收取慣常的收費，並隨時以一星期書面通知取消該授權書。
I/We AGREE that if no transaction is performed on my/our account under such authorisation for a continuous period of 30 months, the Bank reserves the right to
cancel the direct debit arrangement without prior notice to me/us, even though there is no expiry date for the authorisation.
本人/吾等同意如本人/吾等已設立的直接付款授權書的戶口連續三十個月內未有根據授權而作出過賬的紀錄，銀行保留權利取消直接付款安排而毋須另行通知本人/吾
等，即使未有註明授權到期日。
I/We AGREE that any notice of cancellation or variation of this authorisation which I/we may give to my/our Bank shall be given at least two working days
prior to that date on which such cancellation/variation is to take effect.
本人/吾等同意，本人/吾等取消或更改本授權書之任何通知，需於取消/更改生效日最少兩個工作天前交予本人/吾等之銀行。
I/We understand that I/we, if not being the Policy Owner or the Trustee(s), claim no right or title or lien upon the proceeds of below policy(ies).
本人/吾等明白本人/吾等非保單持有人或信託人，並無任何權利於下列保單或在其他收益上有任何權益。

I/We hereby declare that any personal information of third parties provided by me/us to the Company (whether provided under this application or otherwise
provided) in relation to this application has been obtained by me/us in compliance with the PDPO and the relevant third party has agreed to the disclosure of
his/her personal information to the Company in relation to this application for the purposes as set out in this personal information collection statement. I/We
agree to indemnify and hold harmless, on demand, the Company against all losses, liabilities and costs which the Company may incur arising out of, or in
connection with, any breach of the declaration set forth in this paragraph.
本人/吾等特此聲明，由本人/吾等就此申請提供予貴公司的任何第三方個人資料 (無論載於此申請書或從其他途徑所提供) 乃由本人/吾等在遵守個人資料 (私隱) 條例的情
況下獲得，且有關第三方已同意為此等個人資料收集聲明所載之目的就此申請向貴公司提供其個人資料。本人/吾等同意應貴公司要求，就貴公司因發生任何違反本條款
所載的聲明，而可能招致或與之相關的任何損失、責任及費用，對貴公司作出賠償，並使貴公司免受損害。

Personal Information Collection Statement 個人資料收集聲明

I/We confirm that I/we have read and understood the Company’s Personal Information Collection Statement (PICS) made available on the company’s website:
www.hengansl.com.hk > Legal and Privacy Statement > Privacy Statement > Personal Information Collection Statement. By completing and returning this
form, I/we declare and agree that the Company may use my/our personal data in accordance with the PICS, including transferring my/our personal data to the
transferee(s) (in or outside Hong Kong) for direct marketing purposes. I/We understand that I/we have the right to refuse such use and transfer by notifying
the company by email to [email protected] or writing to the company (address can be found on the last page of this form).
本人/吾等確認本人/吾等已閱讀及明白載於貴公司網上 www.hengansl.com.hk > Legal and Privacy Statement > Privacy Statement > Personal Information Collection
Statement 個人資料收集聲明。透過填妥及交回此表格，本人/吾等聲明及同意貴公司可按照個人資料收集聲明使用及轉交本人/吾等的個人資料予不論在本地或海外的受
讓方以作直接促銷用途。本人/吾等理解本人/吾等有權透過電郵至[email protected] 或寫信至貴公司(地址可在表格最後一頁找到)聯絡貴公司以拒絕有關的使用及轉交
行為。 0719HK1852

Heng An Standard Life (Asia) Limited Page 1 of 2

Policy number 保單編號

Please complete all the details shown below:

請填妥以下資料：

Name of Bank and Branch Bank No. Branch No. Bank Account No.
銀行及分行名稱 銀行編號 分行編號 賬戶號碼

English Name(s) of Bank Account Holder(s)

銀行賬戶持有人英文姓名

Until Further Notice

直至另行通知

ID Card / Passport No.* Business Registration / Certificate of Incorporation No. Expiry Date
身份證/護照號碼* (if Account Holder is a company) 到期日
商業登記/公司註冊證書號碼 (如賬戶持有人為公司)

Signature(s) of Bank Account Holder(s)* Date of Signature (dd/mm/yy) Policy Number

銀行賬戶持有人簽署* 簽署日期 (日/月/年) 保單編號

* Please ensure that your provided information and signature are same as you provided to your Bank.
* 請留意閣下的簽署式樣與提供的資料必須與閣下銀行賬戶的一致。

For internal use only 以下由內部填寫

Debtor's Reference Signature Verified

供款人參考 簽署確認

Heng An Standard Life (Asia) Limited (662679) is registered in Hong Kong at 12/F., Lincoln House, Taikoo Place, 979 King’s Road, Quarry Bay, Hong Kong. Authorised
by the Insurance Authority of Hong Kong to write Class A, Class C and Class I long term business in Hong Kong.
恒安標準人壽 (亞洲) 有限公司 (662679) 的註冊公司地址為香港鰂魚涌英皇道979號太古坊林肯大廈12樓，其已獲香港的保險業監管局授權於香港承保 A 類、C 類及 I 類之長
期業務。
0719HK1852

© 2020 Heng An Standard Life (Asia) Limited, reproduced under licence. All rights reserved.
© 2020 恒安標準人壽 (亞洲) 有限公司，已獲授權複製。版權所有，保留一切權利。

Heng An Standard Life (Asia) Limited Page 2 of 2