Alphadirect

Third Party Car Insurance

Plan : R99_R2000000_Cover

Premium : R 99

Vehicle Registration Number * Policy already processed for this vehicle.

Customer Information :

First Name *

Middle Name

Last Name *

ID Type *

National Id *

Marital Status *

Driving License Number *

License valid till: *

Date Of Birth *

Gender *

Male Female

Mobile number *

Email *

Alert! Please do not enter fake email id for the customer.

Address 1*

Address 2

Address 3

Suburb*

Zip Code*

Province *

City / Town *

Source of Income/Funds*:

Vehicle Information :

Is your car imported? *

Yes No

Vehicle Make *

Vehicle Model *

Manufacturing Year *

Are you being assisted by a Broker?*

Yes No

Agent Id :

Please Select Store *

Payment :

From when you would like to start your policy ?*

Billing Date *

Payment method*

Select Bank *

Select Branch *

Account Number *

Confirm Account Number *

Account Type *

I confirm that the insured vehicle will not be used predominantly outside the borders of the Republic of South Africa, or for a period exceeding 30 consecutive days.

All such withdrawals from my/our bank account by GENRIC Insurance Company Limited shall be treated as though they had been signed by me/us personally. I/We understand that the details of each withdrawal will be printed on my bank statement bearing a specific reference number which will reflect REGENRIC and your policy number as confirmed in the policy documents.

This authority may be cancelled by me/us by giving GENRIC Insurance Company Limited 31 days’ notice in writing. However, I/we understand that I/we shall not be entitled to any refund of amounts which GENRIC Insurance Company has withdrawn while this authority was in force, if such amounts were legally owing to GENRIC Insurance Company Limited.

Premiums are payable on a monthly basis by debit order. If two or more debit orders are returned, GENRIC Insurance Company Limited will not be held liable should the policy be automatically terminated, or should claims incurred during this period of suspension not be paid.

I acknowledge that any fees and charges levied by the bank on account of the debit order or any debit order payments which may be rejected for any reason whatsoever will be for my account.

In the event that the payment day falls on a Sunday or recognized public holiday, the payment day will automatically be the very next ordinary business day.

Payment Instructions due in December and/or April may be debited against my account on 15 December or 15 April.

I/we certify that the above bank details are correct. If these banking details have not been provided accurately, or if the details change at any time in the future and I/we fail to notify such changes or if payments are not made in accordance with the Debit Order Instruction, the responsibility of payment will rest with me/us.

I/We acknowledge that this authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the Agreement, this Authority and Mandate cannot be assigned to any third party.

I/We hereby authorise you to issue and deliver payment instructions to your Banker for collection against my/our abovementioned account at my/our above-mentioned Bank (or any other Bank or branch to which I/we may transfer my/our account) on condition that the sum of such payment instructions will never exceed my/our obligations as agreed to in the Agreement.

Create Policy

Customer Information :

Vehicle Information :

Payment :