Authorization for Third Party Premium Payment
This step is required for regulatory reasons when you are making a payment on behalf of a policy holder. We have identified that the policy holder name
and the card holder name are not identical.
This is to place on record that I would be paying the premium amount(s) due for the Policy holder listed in the Policy holder Details section.
I authorize you to accept payment through the debit / credit card that I enter in the next step. I understand and agree that any untimely payment of the above premium will result in suspension / cancellation of the above policy. I also understand and agree that under the Company's Anti Money Laundering Policy the Company may require to carry out due diligence by asking me to submit certain identitification documents.
This authorization stands valid unless revoked by me or by the Policy holder through a written notification.
This is to place on record that I would be paying the premium amount(s) due for the Policy holder listed in the Policy holder Details section.
I authorize you to accept payment through the debit / credit card that I enter in the next step. I understand and agree that any untimely payment of the above premium will result in suspension / cancellation of the above policy. I also understand and agree that under the Company's Anti Money Laundering Policy the Company may require to carry out due diligence by asking me to submit certain identitification documents.
This authorization stands valid unless revoked by me or by the Policy holder through a written notification.