保柏卓康健保柏童康健医疗保障计划更改缴付保费方法及户.PDF

Bupa Care Pro / Bupa Care Kid Health Insurance Scheme Change of Payment Method and Account Number Form 保柏卓康健 / 保柏童康健醫療保障計劃更改繳付保費方法及戶口號碼表 Please complete this form in ENGLISH AND BLOCK LETTERS. Please tick as appropriate. 請以英文正楷填妥本表格，並於適用地方加 「✔」號。 To protect your interest, please return this original form with your signature to Bupa. 為保障閣下的權益，請將本表格正本簽署然後交回保柏 。 Subscriber’s Name Tel No. Fax No. 投保人姓名 電話號碼 傳真號碼 Membership No. (16 digits) Email Address 會員編號 (16位數字) 電郵地址 Types of Changes 更改項目 (Please tick the change(s) and fill in the details as required 請選擇更改部份並填妥所需資料) I. Change of Payment Method 更改繳付保費方法 (Application must be made 3 weeks before the Contract Eective Date 必須於合約生效日三星期前申請) Payment Frequency 繳付保費形式 Payment Method 繳付保費方法 Remarks 備註 Yearly 年繳 Autopay 自動轉賬 Please attach a cheque made payable to “Bupa (Asia) Limited” for the 1st year’s Subscription with a completed Direct Debit Authorisation Form 請填妥直接付款授權書，連同首年保費之支票交回本公司，支票抬頭人為「保柏 （亞洲）有限公司」 Cheque 支票 Please attach a cheque# made payable to “Bupa (Asia) Limited”