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Recurring Credit Card Payment Authorization

I certify that I am an authorized user of this credit card/bank account and hereby authorize the scheduled payments as per my instructions. I undertake to maintain adequate funds to effect the schedule payment transactions and agree to notify HNB Assurance PLC in writing of any changes in my account information or termination of this schedule payments at least 15 days prior to the next billing date. Further , I understand that the schedule payment arrangement will remain in effect unless I notify HNB Assurance PLC in writing to effect the cancellation. I acknowledge that these transactions are governed by & construed in accordance with the law of Sri Lanka.

* Please enter Payment Amount. Eg:100.00
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Dear Customer You Have Already Registered This Policy To Recurring Payments,For More Details Please Contact Customer Care Center ( 011 4 384384 )
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