CARD Mutual Benefit Association, Inc.

A member of CARD MRI

Date: ___________________

MR/MS. ______________________________
Position: ______________________________
Banking Institution: ______________________________
Branch: ______________________________

SUBJECT: AUTHORIZATION TO DEBIT PREMIUM

(BLIP Extension Plan and Golden Life Insurance Program)

Dear _________________,

This is to authorize ________________________________________ to debit the amount of

_________________________________________ (Php ________.00) from my Pledge Savings
Account No. ________________________________ and to be credited to the savings of CARD
MBA Inc. Account No. _____________________________________ as payment for the premium
of BLIP Extension Plan (Php 1,000.00) and initial contribution for Golden Life Insurance
Program (Php ___.00)

Thank you.

AUTHORIZED BY:

_________________________________
Signature Over Printed Name of Member

We have debited/credited above account as instructed:

Signature Verified by: Posted by: Checked by: Approved by:

__________________ _______________ _______________ ___________________

Colago Avenue, Brgy. 1-A, San Pablo City, Laguna 4000, Philippines
Telefax No.: (+6349) 562-2878 / 562-5537 Mobile No.: (+6349) 928-520-5769
Website: www.cardbankph.com E-mail: cardmba9999@cardbankph.com
 CARD Mutual Benefit Association, Inc.
A member of CARD MRI

AUTHORIZATION TO DEDUCT PREMIUM

(BLIP Extension Plan and Golden Life Insurance Program)

Ako si G./Gng./Bb. ___________________________,

(Pangalan) kasapi ng ______________,
(Unit)

_______________
(Center) ay nagnanais na ipagpatuloy ang sakop ng aking seguro sa ilalim ng Basic
Life Insurance Program Extension Plan (BLIPEx) at Golden Life Insurance Program (GLIP).
Bilang pagtugon sa kinakailangang kontribusyon upang masakop ng BLIPEx at GLIP
____________, pinapahintulutan ko ang CARD MBA Inc. na ibawas mula sa aking Equity Value
(Napiling GLIP Option)

o Refund of Contribution na matatanggap mula sa Basic Life Insurance Program ang kabuuang
halaga na __________________________________(PHP ________) bilang kabayaran sa One-
time contribution ng BLIP Extension Plan na Php 1,000.00 at unang kontribusyon para sa
Golden Life Insurance Program na Php _____.00.

_____________________________________
Pangalan at lagda sa ibabaw ng pangalan
Petsa ng Lagdaan: _________________________

Colago Avenue, Brgy. 1-A, San Pablo City, Laguna 4000, Philippines
Telefax No.: (+6349) 562-2878 / 562-5537 Mobile No.: (+6349) 928-520-5769
Website: www.cardbankph.com E-mail: cardmba9999@cardbankph.com