Interbank GIRO
*dda*
APPLICATION FORM
Please remember
• to countersign any amendments • For POSB/DBS Account Holders, you can apply for GIRO via ibanking. For more
• that the use of correction fluid/tape is not allowed details, please visit www.singlife.com/premium-payments
• to return the original form to Singapore Life Ltd.
AUTHORISATION AND DECLARATION
1. I/We hereby instruct and authorise Singapore Life Ltd. (“Singlife”) to debit my/our bank account to pay for my policy/policies.
2. I/We authorise the Bank to reject Singlife’s debit instruction if my/our account does not have sufficient funds and charge me/us a fee for this. The Bank may
also at its discretion allow the debit even if this results in an overdraft on the account and impose charges accordingly.
3. I/We consent to this authorisation being in force until terminated by me/us or upon receipt of my/our written revocation to Singlife.
4. I/We consent to Singapore Life Ltd (“Singlife”) collecting, using and/or disclosing my/our personal data for the processing of the transaction as described in
this form; statistical, research, compliance, audit and regulatory purposes; and such other purposes ancillary or related to the administering of the policy(ies),
account(s) and/or managing my/our relationship with Singlife.
5. I/We also consent to Singlife disclosing and transferring my/our personal data to Singlife related group of companies, third party service providers, reinsurers,
suppliers and intermediaries (including Policy Owner’s(s’) financial adviser, where applicable), whether located in Singapore or elsewhere, for the above
purposes.
6. Where applicable, I/we confirm that for the personal data of other individuals (contained in this form) that I/we have disclosed to Singlife, that I/we have prior
to disclosing such personal data to Singlife, obtained the appropriate consent from the individual(s) to:
(i) permit me/us to collect, use and/or disclose the individual’s(s') personal data to Singlife for the above purposes;
(ii) permit Singlife to collect, use and/or disclose the individual’s(s') personal data for the above purposes; and
(iii) permit Singlife to disclose and/or transfer the individual’s(s') personal data to Singlife related group of companies, third party service providers, reinsurers,
suppliers and intermediaries (including the Policy Owner’s(s’) financial adviser, where applicable), whether located in Singapore or elsewhere, for the
above purposes.
7. I/We have read, understood and agree to be bound by the terms of Singlife's Data Protection Notice (which may be found on https://singlife.com/en/pdpa) as
may be amended, supplemented and/or substituted by Singlife from time to time, and confirm that I/we am/are aware that the latest version of such terms
(amended, supplemented and/or substituted version) will be posted on Singlife’s website and such version shall bind me/us upon posting until such time when
I/we withdraw the consent or revoke the interbank GIRO arrangement indicated here.
1. FOR APPLICANT’S COMPLETION
Date (dd/mm/yyyy): 19 Nov 2023 Billing Organisation: SINGAPORE LIFE LTD.
Bank Name (please tick one bank below): Signature(s) / Thumbprint(s) ^:(as in Bank’s Record)
POSB/DBS UOB
OCBC Standard Chartered
HSBC Others:
Bank Account Holder’s Name(s): Mr/ Mdm/ Ms/ Dr ^ Please sign and mail the original form to us.
Thinn Lei Soe For thumbprint, please visit your bank with identification for verification.
Bank Account Number: 3713057566 Account Holder’s NRIC(s): S8875174D
Policy Number(s)* Policy Owner’s NRIC No. Relationship to Account Holder Reason if Account Holder is not Policy Owner
06212987 S8875174D Self NA
*Please write the Policy Number(s) which you wish to apply for GIRO.
2. FOR OUR COMPLETION
SWIFT BIC Bank Account Number Singapore Life Ltd.’s Customer’s Reference Number
0270007597
DBSSSGSGXXX
0039001886
0039167920
3. FOR BANK’S COMPLETION
To: Singapore Life Ltd.
This application(s) is hereby REJECTED (please tick) for the following reason(s):
Wrong account number
Signature/Thumbprint# differs/irregular# from bank’s records
Amendments not countersigned by Account Holder
Signature/Thumbprint# is incomplete/unclear#
Others
Account operated by Signature/Thumbprint#
# please delete where applicable
Date (DD/MM/YY)
Name of Approving Officer Authorised Signature
PMCGIROFORM.07 (082023)
Singapore Life Ltd. 4 Shenton Way, #01-01, SGX Centre 2 Singapore 068807 Tel: (65) 6827 9933 singlife.com
Company Reg. No. 196900499K GSTReg. No. MR-8500166-8 Page 1/1
