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. Title First Name Last Name Email Address* Phone Number* Address Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands ID Number*Are you selecting the "Family Protect Plan"?* Yes - I am selecting the Family Protect Plan, I am aware of the plan limits No - I am choosing a different plan Pets Details Pet type Pet Name Cat breed Dog breed DOB Gender Actions Edit Delete There are no Pets. 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 selectIntegriSure Brokers (Pty) Ltd – FSP – 14595Authority 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 holderBranch codeBank and branch nameAccount numberAccount 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 December 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.NameThis field is for validation purposes and should be left unchanged.
