RDC

APPLICANT INFORMATION

Title:
Initials:
Surname:
Name:
Phone(w):
I.D number:
Cellphone:
Passport No:
Postal address:
Suburb:
City:
Email:
ZIP Code:
Where did you hear about RoadCover?

DEBIT ORDER DETAILS

Bank Name:
Branch Name:
Account Holders Name:
Account Type:
Account No:
Branch Code:

SPOUSE & DEPENDENTS INFORMATION

Name:
Surname:
Date of Birth:
Relationship:
MEMBERSHIP FEE – R39.00 PER MONTH FOR THE FAMILY
 
The family membership includes the main member, spouse (any person to whom you may be married in terms of South African law, including a party to a customary union according to ethnic law and custom or to a union recognised as a marriage under the tenets of any Asiatic religion, or a person with whom you share a common home with pooled resources, with the intent that this arrangement is permanent), and any dependent child under the age of 21 years, (including adopted, foster and step children, as well as children who are totally physically and/or mentally handicapped and reliant permanently on the support of the main member) who reside in the same residence as the main member.
 
  1. CONTRIBUTIONS
    • PAYMENT: Your contribution of R39.00 will be deducted directly from your bank account. You pay contributions monthly in advance. This means that the deduction in the month is your contribution for the next month.
  2. GENERAL INFORMATION
    • RESIGNATION: You may resign at any time. Kindly note that RoadCover requires a notice period of one calendar month.
 
I hereby confirm that the RoadCover membership services were explained to me and I confirm my acceptance of this membership.
 
I hereby irrevocably authorize RoadCover to debit my account with: R39.00 on the
day of each month