Transcript Title goes here

UAE Direct Debit
Please complete one of the following,
using the abbreviation codes in capitals
& then the corresponding number from
your ID
• Passport number - PASSP
• Emirates ID number - EIDAC
• Driving licence number - DRVLN
• Family Book number - FAMBK
This will be completed by Now
Health
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1.
2.
3.
4.
5.
6.
7.
Name of the Bank i.e. Citi Bank / Emirates NBD
Name that appears on the bank account i.e. Mr John Smith
N/A - Already complete
IBAN number – This will start with AE and will be followed by 21 numbers
N/A – As this is provided on application form
N/A – As this is provided on application form
N/A - Already completed
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8. Start date of your Now Health policy
9. End date of your Now Health policy
10. Already completed
11. Payment frequency - please select payment frequency as mentioned on your invoice
12. This is your USD installment premium multiplied by 3.68 to convert into AED
13. Same value as section 12
14. Already completed – Please note only AED payments can be taken by direct debit
if you are unsure about any field, please let us know and they can be completed by Now Health on your behalf if required
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Agreement and Authorization
By signing in the box below, I/we instruct and authorise you to pay Direct Debits from
my/our account to the Creditor at its account with the Creditor Bank on the basis of
the information provided in this Mandate, and in accordance with the terms and
conditions of this Mandate set out in the form, the Rules of the UAEDDS and any
additional terms and conditions governing my bank accounts or relationship with you.
Where this Mandate is being signed by a corporate entity, the undersigned is an
authorized signatory for the entity.
I/we confirm I/we have read and understood the terms and conditions applying to this
Mandate as set out in this form
Payer Name, Signature & Date*
/
"
I/We have read and understood the term and conditions printed overleaf.
/
/
.
.
/
.
Signature
Verified
,
"
Name /
Signature /
/
[ I have]/[ I have not] left the Minimum amount as blank
[ I have]/[ I have not] left the Maximum amount as blank
Please print your name, sign and date the form
Please send the form back to
Customer Service
Now Health International
Ground Floor,
Al Shaiba Building,
PO Box 502163,
Dubai, UAE
T | +971 (0)4 450 1410
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