"*" indicates required fields 1Application2Policyholder Details3Pets Details4Policy And Premiums Payable PAWesome, you are one step closer to becoming part of the PawPaw pet family Understanding the next steps: This is an application for your pet to join PawPaw Pet Health Insurance, the policy will incept on the 1 st day of the following month. You have 14 days from receipt of your policy documents to cancel from inception date should you not wish to proceed with the cover, thereafter the cancelation period is 30 days written notice. This information is needed to provide upfront underwriting terms (Based on the information provided we may request additional medical history of your pet for underwriting purposes). PawPaw is a product distributed through Brokers, please select one of our Pet Expert Brokers to represent you - NO EXTRA COST to you as the policyholder. Once the form is completed, you will receive notification confirming your request for insurance. DONE. 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Title First Name Last Name Email Address* Phone Number* Pets DetailsPlease 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 HiddenBroker selectionPlease selectAccolade Financial Planning Services (Pty) Ltd Econorisk Broker Consultants (PTY) Ltd Genesis Insurance Brokers (Pty) Ltd Gib Insurance Brokers (Pty) Ltd IF Administrators PTY LTD Indwe Risk Services (Pty) Ltd Kapara Insurance Brokers (Pty) Ltd Majestic Financial Services cc O’Neill’s Risk and Financial Management (Pty) LtdColeman Insurance Brokers CC HTI INSURANCE BROKERS (PTY) LTD HULLEY VAN WYK AND GARRUN (PTY) LTD JH Allen & Associates CC McGuinness Insurance Brokers NMM Insurance Brokers Pty Ltd Winsure Consulting (PTY) LtdEconorisk Broker Consultants (PTY) Ltd FINTEK CC G van Cuyck Insurance Consultants Indwe Risk Services (Pty) Ltd Misure Brokers (Pty) Ltd Specialised Broker Services (Pty) LtdColonial 1952 Pty LtdA Wienburg & Company (Pty) Ltd BellRyck Insurance Brokers Cosmos Brokers FINTEK CC G van Cuyck Insurance Consultants JB LE ROUX BROKERS (PTY) LTD Lyall Morgan & Associates (Pty) Ltd Specialised Broker Services (Pty) Ltd STP Insurance 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 Brank 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.