UAE Direct Debit

2

This will be completed by Now Health

Please complete one of the following using the abbreviation codes in capitals amp then the corresponding number from your ID bull Passport number - PASSPbull Emirates ID number - EIDACbull Driving licence number - DRVLNbull Family Book number - FAMBK

3

1 Name of the Bank ie Citi Bank Emirates NBD2 Name that appears on the bank account ie Mr John Smith3 NA - Already complete4 IBAN number ndash This will start with AE and will be followed by 21 numbers 5 NA ndash As this is provided on application form 6 NA ndash As this is provided on application form 7 NA - Already completed

4

8 Start date of your Now Health policy 9 End date of your Now Health policy10 Already completed11 Payment frequency - please select payment frequency as mentioned on your invoice 12 This is your USD installment premium multiplied by 368 to convert into AED13 Same value as section 12 14 Already completed ndash 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

5

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

ν ϳϭϔΗϭΔϳϗΎϔΗ ϥϣέηΎΑϣϟ ϡλ ΧϟϕϳέρϥϋϊϓΩϟ ϡϛο ϭϔϧϭϡϛϧϣΏϠρϧΎϧϧ ϲϧϧΈϓˬϩΎϧΩϊΑέϣϟϝΧΩϊϳϗϭΗϟΎΑ

ϙϧΑϯΩϟϪΑΎγΣϲϓϥ ΩϟϰϟΎϧΑΎγΣ ϲΑΎγΣϥΩϟνˬ ϳϭϔΗϟΫϫϲϓΓέϓϭϣϟΕΎϣϭϠόϣϟϰϠϋΎϧΑ˯ ϡλ ΧϠϟΕ έΎϣϹϡΎυϧΩϋ ϭϗϭΔϣυϧϭˬΝΫϭϣϧϟ ΫϫϲϓΎϬϳϠϋι ϭλ ϧϣϟ ϪϣΎϛΣϭϪρϭέηΏΟϭϣΑϭ

ΎϬϳϓϊϳϗϭΗϟ ϡΗϳϲΗϟ ΔϟΎΣϟϲϓϭ ϡϛόϣϲΗϗϼϋϭ ΔϳϛϧΑϟϲΗΎΑΎγΣϡϛΣΗϯέΧ ϡΎϛΣϭρϭέηϱ ϭέηΎΑϣϟΔϛέηϟϥϋΔΑΎϳϧϊϳϗϭΗϟΎΑϝϭΧϣϟ ι ΧηϟϭϫϩΎϧΩ ϊϗϭϣϟϥΈϓˬΔϛέηΔργ ϭΑν ϳϭϔΗϟ ΫϫϰϠϋ

ι ϭλ ϧϣϭϫΎϣΑγΣν ϳϭϔΗϟ ΫϫϰϠϋΔϘΑρϧϣϟ ϡΎϛΣϷϭρϭέηϟΕϣϬϔΗϭΕ έϗΩϗϲϧϧ ΫϬΑΩϛ ϧΩϛ ΝΫϭϣϧϟΫϫϲϓΎϬϳϠϋ

Payer Name Signature amp DateΦϳέΎΘϟϭϊ ϴϗϮΘϟ ϊ ϓΪϟϢγ

I We have read and understood the term and conditions printed overleaf ΩϘϟ ΕέϗΎϧέϗ ΕϣϬϔΗϭΎϧϣϬϔΗ ρϭέηϟ ϡΎϛΣϷϭ ΓΩέϭϟ ϲϓ ΔΣϔλϟ ΔϳϟΎΗϟ

[ I have] [ I have not] left the Minimum amount as blank [ I have] [ I have not] left the Maximum amount as blank

Signature Verified

ϊ ϴϗϮΘϟ

Name Ϣγϻ

Signature ϊ ϴϗϮΘϟ

Please print your name sign and date the form

Please send the form back to Customer Service Now Health InternationalGround Floor Al Shaiba Building PO Box 502163 Dubai UAET | +971 (0)4 450 1410

• UAE Direct Debit
• Slide 2
• Slide 3
• Slide 4
• Slide 5

2

This will be completed by Now Health

Please complete one of the following using the abbreviation codes in capitals amp then the corresponding number from your ID bull Passport number - PASSPbull Emirates ID number - EIDACbull Driving licence number - DRVLNbull Family Book number - FAMBK

3

1 Name of the Bank ie Citi Bank Emirates NBD2 Name that appears on the bank account ie Mr John Smith3 NA - Already complete4 IBAN number ndash This will start with AE and will be followed by 21 numbers 5 NA ndash As this is provided on application form 6 NA ndash As this is provided on application form 7 NA - Already completed

4

8 Start date of your Now Health policy 9 End date of your Now Health policy10 Already completed11 Payment frequency - please select payment frequency as mentioned on your invoice 12 This is your USD installment premium multiplied by 368 to convert into AED13 Same value as section 12 14 Already completed ndash 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

5

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

ν ϳϭϔΗϭΔϳϗΎϔΗ ϥϣέηΎΑϣϟ ϡλ ΧϟϕϳέρϥϋϊϓΩϟ ϡϛο ϭϔϧϭϡϛϧϣΏϠρϧΎϧϧ ϲϧϧΈϓˬϩΎϧΩϊΑέϣϟϝΧΩϊϳϗϭΗϟΎΑ

ϙϧΑϯΩϟϪΑΎγΣϲϓϥ ΩϟϰϟΎϧΑΎγΣ ϲΑΎγΣϥΩϟνˬ ϳϭϔΗϟΫϫϲϓΓέϓϭϣϟΕΎϣϭϠόϣϟϰϠϋΎϧΑ˯ ϡλ ΧϠϟΕ έΎϣϹϡΎυϧΩϋ ϭϗϭΔϣυϧϭˬΝΫϭϣϧϟ ΫϫϲϓΎϬϳϠϋι ϭλ ϧϣϟ ϪϣΎϛΣϭϪρϭέηΏΟϭϣΑϭ

ΎϬϳϓϊϳϗϭΗϟ ϡΗϳϲΗϟ ΔϟΎΣϟϲϓϭ ϡϛόϣϲΗϗϼϋϭ ΔϳϛϧΑϟϲΗΎΑΎγΣϡϛΣΗϯέΧ ϡΎϛΣϭρϭέηϱ ϭέηΎΑϣϟΔϛέηϟϥϋΔΑΎϳϧϊϳϗϭΗϟΎΑϝϭΧϣϟ ι ΧηϟϭϫϩΎϧΩ ϊϗϭϣϟϥΈϓˬΔϛέηΔργ ϭΑν ϳϭϔΗϟ ΫϫϰϠϋ

ι ϭλ ϧϣϭϫΎϣΑγΣν ϳϭϔΗϟ ΫϫϰϠϋΔϘΑρϧϣϟ ϡΎϛΣϷϭρϭέηϟΕϣϬϔΗϭΕ έϗΩϗϲϧϧ ΫϬΑΩϛ ϧΩϛ ΝΫϭϣϧϟΫϫϲϓΎϬϳϠϋ

Payer Name Signature amp DateΦϳέΎΘϟϭϊ ϴϗϮΘϟ ϊ ϓΪϟϢγ

I We have read and understood the term and conditions printed overleaf ΩϘϟ ΕέϗΎϧέϗ ΕϣϬϔΗϭΎϧϣϬϔΗ ρϭέηϟ ϡΎϛΣϷϭ ΓΩέϭϟ ϲϓ ΔΣϔλϟ ΔϳϟΎΗϟ

[ I have] [ I have not] left the Minimum amount as blank [ I have] [ I have not] left the Maximum amount as blank

Signature Verified

ϊ ϴϗϮΘϟ

Name Ϣγϻ

Signature ϊ ϴϗϮΘϟ

Please print your name sign and date the form

Please send the form back to Customer Service Now Health InternationalGround Floor Al Shaiba Building PO Box 502163 Dubai UAET | +971 (0)4 450 1410

• UAE Direct Debit
• Slide 2
• Slide 3
• Slide 4
• Slide 5

3

1 Name of the Bank ie Citi Bank Emirates NBD2 Name that appears on the bank account ie Mr John Smith3 NA - Already complete4 IBAN number ndash This will start with AE and will be followed by 21 numbers 5 NA ndash As this is provided on application form 6 NA ndash As this is provided on application form 7 NA - Already completed

4

8 Start date of your Now Health policy 9 End date of your Now Health policy10 Already completed11 Payment frequency - please select payment frequency as mentioned on your invoice 12 This is your USD installment premium multiplied by 368 to convert into AED13 Same value as section 12 14 Already completed ndash 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

5

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

ν ϳϭϔΗϭΔϳϗΎϔΗ ϥϣέηΎΑϣϟ ϡλ ΧϟϕϳέρϥϋϊϓΩϟ ϡϛο ϭϔϧϭϡϛϧϣΏϠρϧΎϧϧ ϲϧϧΈϓˬϩΎϧΩϊΑέϣϟϝΧΩϊϳϗϭΗϟΎΑ

ϙϧΑϯΩϟϪΑΎγΣϲϓϥ ΩϟϰϟΎϧΑΎγΣ ϲΑΎγΣϥΩϟνˬ ϳϭϔΗϟΫϫϲϓΓέϓϭϣϟΕΎϣϭϠόϣϟϰϠϋΎϧΑ˯ ϡλ ΧϠϟΕ έΎϣϹϡΎυϧΩϋ ϭϗϭΔϣυϧϭˬΝΫϭϣϧϟ ΫϫϲϓΎϬϳϠϋι ϭλ ϧϣϟ ϪϣΎϛΣϭϪρϭέηΏΟϭϣΑϭ

ΎϬϳϓϊϳϗϭΗϟ ϡΗϳϲΗϟ ΔϟΎΣϟϲϓϭ ϡϛόϣϲΗϗϼϋϭ ΔϳϛϧΑϟϲΗΎΑΎγΣϡϛΣΗϯέΧ ϡΎϛΣϭρϭέηϱ ϭέηΎΑϣϟΔϛέηϟϥϋΔΑΎϳϧϊϳϗϭΗϟΎΑϝϭΧϣϟ ι ΧηϟϭϫϩΎϧΩ ϊϗϭϣϟϥΈϓˬΔϛέηΔργ ϭΑν ϳϭϔΗϟ ΫϫϰϠϋ

ι ϭλ ϧϣϭϫΎϣΑγΣν ϳϭϔΗϟ ΫϫϰϠϋΔϘΑρϧϣϟ ϡΎϛΣϷϭρϭέηϟΕϣϬϔΗϭΕ έϗΩϗϲϧϧ ΫϬΑΩϛ ϧΩϛ ΝΫϭϣϧϟΫϫϲϓΎϬϳϠϋ

Payer Name Signature amp DateΦϳέΎΘϟϭϊ ϴϗϮΘϟ ϊ ϓΪϟϢγ

I We have read and understood the term and conditions printed overleaf ΩϘϟ ΕέϗΎϧέϗ ΕϣϬϔΗϭΎϧϣϬϔΗ ρϭέηϟ ϡΎϛΣϷϭ ΓΩέϭϟ ϲϓ ΔΣϔλϟ ΔϳϟΎΗϟ

[ I have] [ I have not] left the Minimum amount as blank [ I have] [ I have not] left the Maximum amount as blank

Signature Verified

ϊ ϴϗϮΘϟ

Name Ϣγϻ

Signature ϊ ϴϗϮΘϟ

Please print your name sign and date the form

Please send the form back to Customer Service Now Health InternationalGround Floor Al Shaiba Building PO Box 502163 Dubai UAET | +971 (0)4 450 1410

• UAE Direct Debit
• Slide 2
• Slide 3
• Slide 4
• Slide 5

4

8 Start date of your Now Health policy 9 End date of your Now Health policy10 Already completed11 Payment frequency - please select payment frequency as mentioned on your invoice 12 This is your USD installment premium multiplied by 368 to convert into AED13 Same value as section 12 14 Already completed ndash 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

5

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

ν ϳϭϔΗϭΔϳϗΎϔΗ ϥϣέηΎΑϣϟ ϡλ ΧϟϕϳέρϥϋϊϓΩϟ ϡϛο ϭϔϧϭϡϛϧϣΏϠρϧΎϧϧ ϲϧϧΈϓˬϩΎϧΩϊΑέϣϟϝΧΩϊϳϗϭΗϟΎΑ

ϙϧΑϯΩϟϪΑΎγΣϲϓϥ ΩϟϰϟΎϧΑΎγΣ ϲΑΎγΣϥΩϟνˬ ϳϭϔΗϟΫϫϲϓΓέϓϭϣϟΕΎϣϭϠόϣϟϰϠϋΎϧΑ˯ ϡλ ΧϠϟΕ έΎϣϹϡΎυϧΩϋ ϭϗϭΔϣυϧϭˬΝΫϭϣϧϟ ΫϫϲϓΎϬϳϠϋι ϭλ ϧϣϟ ϪϣΎϛΣϭϪρϭέηΏΟϭϣΑϭ

ΎϬϳϓϊϳϗϭΗϟ ϡΗϳϲΗϟ ΔϟΎΣϟϲϓϭ ϡϛόϣϲΗϗϼϋϭ ΔϳϛϧΑϟϲΗΎΑΎγΣϡϛΣΗϯέΧ ϡΎϛΣϭρϭέηϱ ϭέηΎΑϣϟΔϛέηϟϥϋΔΑΎϳϧϊϳϗϭΗϟΎΑϝϭΧϣϟ ι ΧηϟϭϫϩΎϧΩ ϊϗϭϣϟϥΈϓˬΔϛέηΔργ ϭΑν ϳϭϔΗϟ ΫϫϰϠϋ

ι ϭλ ϧϣϭϫΎϣΑγΣν ϳϭϔΗϟ ΫϫϰϠϋΔϘΑρϧϣϟ ϡΎϛΣϷϭρϭέηϟΕϣϬϔΗϭΕ έϗΩϗϲϧϧ ΫϬΑΩϛ ϧΩϛ ΝΫϭϣϧϟΫϫϲϓΎϬϳϠϋ

Payer Name Signature amp DateΦϳέΎΘϟϭϊ ϴϗϮΘϟ ϊ ϓΪϟϢγ

I We have read and understood the term and conditions printed overleaf ΩϘϟ ΕέϗΎϧέϗ ΕϣϬϔΗϭΎϧϣϬϔΗ ρϭέηϟ ϡΎϛΣϷϭ ΓΩέϭϟ ϲϓ ΔΣϔλϟ ΔϳϟΎΗϟ

[ I have] [ I have not] left the Minimum amount as blank [ I have] [ I have not] left the Maximum amount as blank

Signature Verified

ϊ ϴϗϮΘϟ

Name Ϣγϻ

Signature ϊ ϴϗϮΘϟ

Please print your name sign and date the form

Please send the form back to Customer Service Now Health InternationalGround Floor Al Shaiba Building PO Box 502163 Dubai UAET | +971 (0)4 450 1410

• UAE Direct Debit
• Slide 2
• Slide 3
• Slide 4
• Slide 5

5

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

ν ϳϭϔΗϭΔϳϗΎϔΗ ϥϣέηΎΑϣϟ ϡλ ΧϟϕϳέρϥϋϊϓΩϟ ϡϛο ϭϔϧϭϡϛϧϣΏϠρϧΎϧϧ ϲϧϧΈϓˬϩΎϧΩϊΑέϣϟϝΧΩϊϳϗϭΗϟΎΑ

ϙϧΑϯΩϟϪΑΎγΣϲϓϥ ΩϟϰϟΎϧΑΎγΣ ϲΑΎγΣϥΩϟνˬ ϳϭϔΗϟΫϫϲϓΓέϓϭϣϟΕΎϣϭϠόϣϟϰϠϋΎϧΑ˯ ϡλ ΧϠϟΕ έΎϣϹϡΎυϧΩϋ ϭϗϭΔϣυϧϭˬΝΫϭϣϧϟ ΫϫϲϓΎϬϳϠϋι ϭλ ϧϣϟ ϪϣΎϛΣϭϪρϭέηΏΟϭϣΑϭ

ΎϬϳϓϊϳϗϭΗϟ ϡΗϳϲΗϟ ΔϟΎΣϟϲϓϭ ϡϛόϣϲΗϗϼϋϭ ΔϳϛϧΑϟϲΗΎΑΎγΣϡϛΣΗϯέΧ ϡΎϛΣϭρϭέηϱ ϭέηΎΑϣϟΔϛέηϟϥϋΔΑΎϳϧϊϳϗϭΗϟΎΑϝϭΧϣϟ ι ΧηϟϭϫϩΎϧΩ ϊϗϭϣϟϥΈϓˬΔϛέηΔργ ϭΑν ϳϭϔΗϟ ΫϫϰϠϋ

ι ϭλ ϧϣϭϫΎϣΑγΣν ϳϭϔΗϟ ΫϫϰϠϋΔϘΑρϧϣϟ ϡΎϛΣϷϭρϭέηϟΕϣϬϔΗϭΕ έϗΩϗϲϧϧ ΫϬΑΩϛ ϧΩϛ ΝΫϭϣϧϟΫϫϲϓΎϬϳϠϋ

Payer Name Signature amp DateΦϳέΎΘϟϭϊ ϴϗϮΘϟ ϊ ϓΪϟϢγ

I We have read and understood the term and conditions printed overleaf ΩϘϟ ΕέϗΎϧέϗ ΕϣϬϔΗϭΎϧϣϬϔΗ ρϭέηϟ ϡΎϛΣϷϭ ΓΩέϭϟ ϲϓ ΔΣϔλϟ ΔϳϟΎΗϟ

[ I have] [ I have not] left the Minimum amount as blank [ I have] [ I have not] left the Maximum amount as blank

Signature Verified

ϊ ϴϗϮΘϟ

Name Ϣγϻ

Signature ϊ ϴϗϮΘϟ

Please print your name sign and date the form

Please send the form back to Customer Service Now Health InternationalGround Floor Al Shaiba Building PO Box 502163 Dubai UAET | +971 (0)4 450 1410

• UAE Direct Debit
• Slide 2
• Slide 3
• Slide 4
• Slide 5