Road Protect
Application Form
Title:
Surname:
Full Names:
ID Number:
Cell No.:
Home No.:
Email Address:
Spouse Name.:
Tel Number:
Physical Home Address:
Postal Code:
Postal Address:
Postal Code:
Car registration number:
Tick one or more of the blocks below to sign up for these benefits, all prices below exclude VAT;
Accident Protect - R30, 70 per member per month (or R350,88 per annum)
Pothole Protect - 30, 70 per member per month (or R350,88 per annum)
Fines Protect - R35, 09 per member per month (or R394,74 per annum)
Please select a payment type:
EFT Payment
Annual Debit Order
EFT Payment:
Account Name -
Road Protect (Pty) Ltd
Bank -
Nedbank
Account Number -
1021606162
Branch Code -
12850500
Reference Number -
Your I.D Number
Annual Debit Order:
Note the chosen fee will be debited on an on-going basis off your account unless you notify us of your wish to cancel your membership. Please contact the Callcentre on 011 291 7300 or at callcentre@oneloyalty to cancel your membership or change your personal details.
Account Name
Bank Name
Account Number
Branch
Branch Code
Reference Number
Road Protect
Date:
Day
Month
Year
Place:
A call centre consultant will contact you shortly to confirm your membership.