Pet Insurance Digital Quote

Policyholder Details

Title

First Name

Last Name

Email Address

Contact No

ID Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pet Details

Are you selecting the "Pack Plan"?

I have read the terms & conditions and I am aware of the plan limits.

Policy & Premiums Payable

Pack Plan Pet Insurance

Price:

Comprehensive Pet Insurance

Price: R160.00

Inception Date

Immediate inception (Your policy will incept on the first business day following receipt of your acceptance of the terms and conditions of the quote and your completed debit order mandate for monthly paying policies, or receipt of your annual premium via EFT for annual paying policies. Monthly paying policies will be subject to a first pro-rata premium collection.) or 1st of the following month (Your policy will incept on the first of the following calendar month, following the timely receipt of your acceptance of the terms and conditions of the quote and your completed debit order mandate for monthly paying policies, or receipt of your annual premium via EFT for annual paying policies.)

Authority to Debit Account

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

Account No

Bank Name

Bank Code

Account Type

Debit Day

I request and authorise Renasa Insurance Co Ltd to draw against the above mentioned account, the amount necessary for payment of the monthly premium, as and when, required. This amount will debit every month until this arrangement is cancelled 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 selected P.UMA reserves the right to select the last working day of each month.

DECLARATION
I 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. 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 validation by electronic signature

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.

Digital Signature(Required)

Type your RSA ID no(Required)

Type your Full Name & Surname(Required)