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: Account Name - Road Protect (Pty) Ltd
Bank - Nedbank
Account Number - 1021606162
Branch Code - 12850500
Reference Number - Your I.D Number
Place:
A call centre consultant will contact you shortly to confirm your membership.