Join | PawPaw Pet Insurance - trusted for over a decade

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*

Title First Name Last Name

Email Address*

Phone Number*

Address

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

ID Number*

Are you selecting the "Pack Plan"?*

Yes - I am selecting the Pack 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
There are no Pets.

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

Signup channel*

Online

Agent sale

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.)

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.)

Broker selection

Agent name*

Call reference number

Authority to debit account

The 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

0 of 6 max characters

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 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. 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 signature

Client validation by electronic signature

Type 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.

Name

This field is for validation purposes and should be left unchanged.

PAW-SOME!

You are one step closer to becoming part of the PawPaw pet family!

What to expect next:

Final Calculation

Authority to debit account

Client validation by electronic signature

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