PAW-SOME! You are one step closer to becoming part of the PawPaw pet family! What to expect next: "*" indicates required fields 1Application2Policyholder Details3Pets Details4Policy And Premiums Payable This is an application for your pet to join PawPaw Pet Insurance. Your personal details as policyholder will be required, as well as that of your pet, and your veterinary provider of choice. PawPaw Pet Insurance is a product distributed through our Pet Expert Brokers, who will represent you at no extra cost. Once the form is completed, you will receive notification confirming your request for pet insurance. Name* Dr.MissMr.Mrs.Ms.Prof.Rev. 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Add Pet Maximum number of pets reached. Please enter details of the pets to be insured PLEASE NOTE: you have the option to pay your premium annually. If you select this option, one of our friendly consultants will be in touch with you to set that up.Final Calculation Total monthly premium: Total annual premium: Payment option* Monthly Annually Broker selectionPlease selectFINTEK CC Gib Insurance Brokers (Pty) Ltd Majestic Financial Services ccGo Insure Insurance Brokers (Pty) Ltd McGuinness Insurance Brokers Misure Brokers (Pty) LtdCosmos Brokers Majestic Financial Services cc Misure Brokers (Pty) LtdAuthority to debit accountThe following segment is optional. Should you simply require a quote, skip this segment and we'll capture your banking details at a later stage once you wish to proceed with cover and incept the policy.Account holder Branch code Bank and branch name Account number Account type Cheque Savings Debit Day 1st 7th 15th I request and authorise Renasa Insurance Co Ltd to draw against the above mentioned account, the amount necessary forpayment of the monthly premium, as and when, required. This amount will debit every month until this arrangement iscancelled in writing by either party.I accept that, if the debit date falls on a weekend, I will be debited on the subsequent working day. If no debit date is selectedP.UMA reserves the right to select the last working day of each month. DECLARATIONI hereby confirm that all details supplied above are true and correct to the best of my knowledge. NB: Any false disclosure could result in the policy being made void. This policy will be renewed on 1 June each year. You will be informed of any changes 30 days prior to renewal. By signing below, I hereby accept all terms and conditions (available by clicking here) related to this policy and authorise the premium to be debited off my account. By completing this application form you consent to us obtaining any veterinary histories required from your treating vets in order for us to underwrite this risk. All your information will be treated in the strictest confidence at all times.Client signatureClient validation by electronic signatureType your RSA ID no* Type your full name/s + surname* These are important documents & should be kept for reference purposes. A copy of the details entered will be sent to us for processing, and a reference copy will be emailed to you (at the email address you've entered) for your records.EmailThis field is for validation purposes and should be left unchanged.