ACCIDENT RECOVERY INSURANCE - YOUR DETAILS

Superior - $33.26 a month
Standard - $20.90 a month

Superior - $31.60 a month
Standard - $19.86 a month

EasyPay payment options:	Credit Card online Direct Debit online
Credit Card Details Card type: -Select-VisaMasterCardAmerican ExpressDiners Card Cardholder's Name: Card Number: (Please do not use any spaces) Expiry Date: Month020304050607080910111201Year20122013201420152016
Direct Debit Online Details Do you have individual signing authority on the chosen account?  Yes  No Unfortunately we are unable to offer Direct Debit EasyPay where two or more signatures are required on your chosen bank account. Please use an account that you do have individual signing authority on, or choose a different method of payment. Name of Account: Account Number: Bank Branch Account Suffix

Other payment options:	Direct Debit Authority Cheque
Direct Debit Details I will download a Direct Debit form here:    Direct Debit Form Please send me a Direct Debit form.
Cheque Details Cheques can only be accepted for quarterly, half yearly and yearly premium payments. Please make your cheque payable to Asteron Life Limited, print your name, address and phone number on the back and send it freepost to:   AA Life Freepost 198921 PO Box 3369 Wellington.