CMB Wing Lung

HK Time 2009/02/01 20:18

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Name of Insured Person (i.e. Credit Card Holder)

(Surname, Given Name)

Correspondence Address:

E-mail Address:

Telephone No.:

(Home)

(Office)

(Mobile)

Occupation:

Date of Birth:

(yyyy/mm/dd)

Policy Commencement Date:

(yyyy/mm)

Name of Beneficiary:

Relationship with Insured Person:

Cover Type (Please select either one):

Cover 1 Cover 2

Collection of Policy:

to be mailed to correspondence address

to be collected at branch

Premium Payment Account:

Credit Card
I hereby authorize CMB Wing Lung Insurance Co. Ltd to debit from my Credit Card account the premium of the cover type selected.

VISA MasterCard:

- - -

Card Expiry Date:

(yyyy/mm)

Name of Credit Card Holder:

Declaration

1.	I/We hereby apply for insurance as set out in the Company's Credit Protect Policy, and I/we hereby warrant that the above particulars are true and agree that this proposal shall be the basis of the contract between myself/ourselves and the Company.
2.	I have read, understand and agree with the terms & conditions related to this insurance. I also agree to provide personal information to the Company for application of insurance.
3.	I agree to be abided by the Credit Protect Terms to be sent to me later.
4.	I also agree that:
4.	This offer is for holders of valid CMB Wing Lung Bank Credit Card (including affinity card) only. Acceptance of application is subjected to the customer's financial situation, available balance, and approval of the Company and CMB Wing Lung Bank.

Customer Service Hotline: 2952 6666