PET INSURANCE APPLICATION FORM

PAWesome, you are one step closer to becoming part of the PawPaw pet family!

Understanding the Next Steps:

1. This is an application for your pet to join PawPaw Pet Health Insurance, the policy will incept on the 1st 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 cancellation period is 30 days written notice.

2. 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).

3. PawPaw is a product distributed through our brokers- GVC BROKERS - at no extra cost to you as the policyholder.

4. Once the form is completed, you will receive a notification confirming your request for insurance.

5. If you are not yet sure which Pet Insurance Cover you would like to take out for your pet, a full Product Breakdown and Description can be found in this link.

Thank you for using www.PetHealthcare.co.za to sign up for Pawpaw Pet Insurance.

Please Keep Scrolling Down
PetHealthcare.co.za brokers are G Van Cuyck Insurance Consultants FSP No 12925

PawPaw is administered by P.UMA on behalf of Renasa Insurance Company.
Insurer: Renasa Insurance Company Ltd - FSP No. 15491. Underwriting Manager: Pet Underwriting Managing Agency - FSP No. 44387

Quick Fill - You choose. Complete application below or we can send one to you?
Name

First NameLast Name
Which do you prefer?

EmailPhone
If you would like for us to communicate with you via email, please enter your email address here.
example@example.com
If you would like us to call you, please enter your phone number here.
Please tick your preferred choices

Call me between 9h00 & 12h00Call me between 12h00 & 17h00
TODAY

MonthDayYear
Date
WOW... these babies must be loved. Let's add pet number four(4)...
4. NAME of PET
4.1 Date of Birth
day - month - year
4. Is this pet adopted / rescued?

YESNO
4.4 If yes, when did you adopt this pet?
day - month - year
STERILIZATION: Has this dog or cat been spayed or neutered?*

YESNO
MALE or FEMALE*

MALEFEMALE
BREED
BONUS BENEFIT ! - Did you know that BREED RELATED conditions are included in this cover? (provided they are not pre-existing.)
Below we will be asking you a few quick questions around any health problems, that {4Name}, may have.

Please take care to answer these questions fully and correctly, for us to be able to give you an accurate quotation, based on the information you provide. We will be retrieving a full veterinary history when you put in your first claim. If there are any pre-existing conditions that you have not let us know about, this could result in us placing endorsements on your policy or your policy being cancelled.*

	YES	NO
1. Has the pet been seen by any other vet besides their regular vet?
2. Has the pet ever been to the vet for any medical problems?
3. Has the pet needed medical treatment now or in the past?
4. Is the pet currently on any medication or prescription food?
5. Has the pet ever exhibited excessive licking or scratching?
6. Has the pet ever had any eye or ear problems?
7. Has this pet ever had severe vomiting or diarrhoea?
8. Does this pet have difficulty rising or walking?
9. Does this pet have any physical abnormalities?
10. Has this pet had any behavioural problems?
11. Are all vaccinations up to date?
12. Has this pet ever been used in competitive or commercial activities?

Please provide the details for all the YES answers above:

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.

Now, let's choose the right product for pet no. 4

Take a look at the premiums and keep in mind what excess you would like for your cover.
4. DOG or CAT*

My DogMy Cat
Cover for your DOG
Cover for your CAT
Please contact me, I have a few more questions.I am happy with everything above, please go ahead.
Your broker is G Van Cuyck Insurance Consultants FSP No 12925

PawPaw is administered by P.UMA on behalf of Renasa Insurance Company.
Insurer: Renasa Insurance Company Ltd - FSP No. 15491. Underwriting Manager: Pet Underwriting Managing Agency - FSP No. 44387
Should be Empty:

WOW... these babies must be loved. Let's add pet number four(4)...

Now, let's choose the right product for pet no. 4