SBC Ada Form

SECURITY DIGIBANKER – Auto Debit Collections Manager (ADCM)
Enrollment Form For FWD LIFE INSURANCE CORPORATION’s Customers
New Enrollment Disenrollment Change Account Number: existing account number Date:
Name of Policyholder:
Ref. No. (8-digit Policy Number):
Company/Merchant/Biller Name: FWD Life Insurance Corporation Product Name: FWD-ADC
Name of Accountholder:
Account No. to be Debited:
Accountholder’s Mobile Number: Accountholder’s Email:
Gentlemen:
This will serve as my authorization to debit my/our Savings/Current /CashLink Plus Accounts listed above to cover the billing of the FWD LIFE INSURANCE
CORPORATION mentioned above under the AutoDebit Collection Arrangement (ADC) with Security Bank DigiBankerTM.
This instruction shall be in effect until revoked in writing by the undersigned.
I/We hereby certify that the above facts are true and correct. I/We hereby agree to be governed by the terms and conditions of the Auto Debit Collection
Arrangement Facility as stated in this form, a copy of which is hereby acknowledged to have been received by me/us. I/We are likewise subject to the
applicable terms and conditions of the Institution/Beneficiary.
TERMS AND CONDITIONS
1. The Bank shall be notified immediately of any and all changes in my/our reference/policy number(s);
2. I/We agree to waive the application of R.A. 1405 (Secrecy of Bank Deposits Law) and hereby authorize the bank to disclose to the mentioned
Company/Institution/Beneficiary on this form any matter pertaining to my/our linked or depository accounts (listed on this form) as may be necessary
for the operation of this AutoDebit Arrangement;
3. Only the cleared and withdrawable balance of the account shall be debited; in the event that there is no withdrawable balance on debit date, my
account/s can be redebited as necessary. If no payment was debited from my account by the Bank for whatever reason, I understand that the
mentioned Company/Institution/Beneficiary will not consider that amount to have been paid. This is without prejudice to my making a separate
arrangement with the Company/Institution/Beneficiary for the settlement of my amount due;
4. Any discrepancy between the billing amount and the debited amount shall be resolved with the mentioned Company/Institution/Beneficiary;
5. Payments made shall be for amounts due;
6. The AutoDebit Collection Arrangement between the Bank and the mentioned Company/Institution/Beneficiary may be cancelled at anytime by either
party without need of prior written notice of termination to me/us;
7. This agreement shall be governed by all applicable rules and regulations of the Bangko Sentral ng Pilipinas;
8. The Bank may in the future impose charges on this arrangement within legal and regulatory limits.
9. All terms and conditions of my/our existing savings/current/CashLink Plus account agreement(s) with the Bank insofar as not inconsistent herewith
shall remain in full force and effect;
10. The Bank shall not be held liable for any adverse actions/consequences instituted by the mentioned Company/Institution/Beneficiary for payment
made on overdue or past due accounts, policy revision, and/or the like;
11. I/We hold the Bank and other members of the Bank as well as any of their officers and representatives free and harmless from any and all liabilities,
claims, demands, suits of whatever nature, arising out of or in connection with the implementation of this arrangement, including any and all errors
and/or omissions inadvertently committed resulting to the Bank’s failure to effect any payment transaction that I/We may undertake via the AutoDebit
Collection Arrangement.
12. The depositor may terminate this authority upon thirty (30) days written notice to the mentioned Company/Institution/Beneficiary.
13. I/We hereby agree to waive separate notice of debit other than that reflected in the Bank’s statement.
     
Signature Over Printed Name of Accountholder Signature Over Printed Name of Accountholder Signature Over Printed Name of Accountholder
NOTE: YOUR SIGNATURE ABOVE SHOULD BE THE SAME WITH YOUR SIGNATURE ON THE SECURITY BANK ACCOUNT OPENING
DOCUMENTS.
FOR BANK USE ONLY:

Date Form Received: Branch Code: Account Number and Signature Verified Correct by:
Form Received By: Approved by:
Note to BRANCH: FORWARD SCANNED COPIES of FWD-ADA enrollment forms to VIRTUAL BANKING (VBSU) after signature
verification. VBSU shall handle all FWD-DIGIBANKER-ADCM ENROLLMENTS. FORWARD HARD COPIES per usual to BBOG –
CDC Records for safekeeping.

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SECURITY DIGIBANKER – Auto Debit Collections Manager (ADCM)

Enrollment Form For FWD LIFE INSURANCE CORPORATION’s Customers

This instruction shall be in effect until revoked in writing by the undersigned.

TERMS AND CONDITIONS

FOR BANK USE ONLY:

Form Received By: Approved by:

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