Please complete the personal details section and the section for your intended payment method and return the form to our customer service team.

I authorise Monument International Life Assurance Limited, until further notice in writing, to debit my credit card account, as detailed below, with unspecified amounts in respect of the premiums for my policy as and when they fall due and in respect of charges for collection of the premiums by credit card that are passed onto me by the company.

I understand that this authority in favour of Monument International will remain in force until such time as I cancel it in writing.

Details of current rates of charges are available on request. Please note that Monument International is not liable for any losses arising as a result of action taken by the cardholder’s credit card company, please contact your credit card provider.

To be completed if you wish to make contributions of variable amounts in sterling or US Dollars on unspecified dates by Mastercard or Visa Credit Card for your regular premium payments on your policy.

To: Monument International

1. All fields to be filled in BLOCK LETTERS only.2. Please provide a copy of the front side of the credit card along with this form.3. Please ensure that your card is valid on the transaction date.4. Your request for credit card payment option should be submitted at least 10 days prior to your next premium due date.

Credit card number:

Expiry Date: Address (as held by the credit card company):

CREDIT CARD

PAYMENT METHODS PLEASE COMPLETE ONE METHOD OF PAYMENT ONLY

M M Y Y Y Y

1

Policy number(s):

Policyholder(s):

Credit card issuer (Name of bank):

Credit-card type: VISA / MASTERCARD please delete one. Currency of card:

Name on credit card:

Postcode/Zip

I understand that this authority in favour of Monument International will remain in force until such time as I cancel it in writing.

Card holder signature Date

8D D M M Y Y Y Y

2

PAYMENT METHODS PLEASE COMPLETE ONE METHOD OF PAYMENT ONLY

FUNDS TRANSFER

SECTION A – FOR POLICYHOLDERS REMITTING IN STERLING FROM UK BASED BANK ACCOUNTS

SECTION B – GENERAL INFORMATION/AUTHORISATION FOR PAYMENT

Notes for guidance

Please use BLOCK CAPITALS and either blue or black ink.

For clients remitting in Sterling from UK based accounts only, payment can be made by providing the paying institution with the account details in Section A below.

For all other remittances, payment can be made by completing Section B and providing the paying institution with the instructions contained in Section C below.

*Please quote the policy number and/or policyholder’sfull name.

Account name Monument International

Account number 43663191

Branch name Douglas, Isle of Man

Sort code 40-19-38

Reference*

Name of bank

Bank Address

Postcode/Zip

Account holder name

Account number

Currency Amount (figures)

Amount (words)

Reference*

3

PAYMENT METHODS PLEASE COMPLETE ONE METHOD OF PAYMENT ONLY

SECTION C

Important: Payment must be made via your international division only, using the SWIFT remitting system.

Failure to adhere to remittance instructions could result in funds being delayed or returned.

In the event of funds being lost/delayed please note that it is the responsibility of the remitting institution to trace, redirect and compensate for incorrectly completed transfers.

Please select the appropriate Monument International account with HSBC London by reference to the currency denomination set out in Section B.

The actual remittance should be the amount detailed in Part B i.e. any transfer charges due should not be taken from this amount.

Currency denomination GBP EURO USD

Intermediary bank HSBC International HSBC Bank plc HSBC Bank USA

Intermediary bank SWIFT address

MIDLIM21XXX N/a MRMDUS33

Beneficiary’s bank HSBC London HSBC London HSBC London

Beneficiary’s bank SWIFT address

MIDLGB22 MIDLGB22 MIDLGB22

Beneficiary Monument International Monument International Monument International

Beneficiary’s account number

43663191 59089457 59089430

Beneficiary’s IBAN code GB73 MIDL 4019 3843 6631 91

GB17 MIDL 4005 1559 0894 57

GB67 MIDL 4005 1559 0894 30

Signature(s) Date

Date

8

8

D D M M Y Y Y Y

D D M M Y Y Y Y

PLEASE FILL IN THE WHOLE FORM INCLUDING OFFICIAL BOX USING A BALL POINT PEN AND SEND TO:

Monument International Life Assurance Company LtdPO Box 391Douglas, Isle of Man IM99 2XW

Name(s) of account holder(s)

Bank/building society account number

Sort code

Instruction to your bank or building society to pay by Direct DebitService Number

FOR MONUMENT INTERNATIONAL LIFE ASSURANCE CO LTD OFFICIAL USE ONLY

This is not part of the instruction to your bank or building society.

The Direct Debit Guarantee• The Direct Debit Guarantee• This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits• If there are any changes to the amount, date or frequency of your Direct Debit Monument International Life Assurance Company Limited will notify

you 20 working days in advance of your account being debited or as otherwise agreed. If you request Monument International Life Assurance Company Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request.

• If an error is made in the payment of your Direct Debit, by Monument International Life Assurance Company Limited or your bank or buildingsociety you are entitled to a full and immediate refund of the amount paid from your bank or building society – If you receive a refund you are not entitled to, you must pay it back when Monument International Life Assurance Company Limited asks you to

• You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

9 1 2 9 5 0

Signature(s)

Date

8

8

D D M M Y Y Y Y

4

PAYMENT METHODS PLEASE COMPLETE ONE METHOD OF PAYMENT ONLY

DIRECT DEBIT

Name of bank

Bank Address

Postcode/Zip