Application Form

Alloy Rims and Tyre Maintenance Plan Application Form

Applicant Information

Name(Required)

First Last

Maiden Name

Cell(Required)

ID Number(Required)

Work Tell

Email(Required)

Postal Code(Required)

Residential Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Tell

Title(Required)

Vehicle Information

Make(Required)

Model(Required)

Year(Required)

Colour

Registration Nr.(Required)

VIN Nr.(Required)

Credit Provider

Dealership Name

Tyre Brand(Required)

Tyre Size(Required)

Alloy Rim(Required)

Stock

Aftermarket

Diamond cut(Required)

Yes

AutoGuard Plan Chosen (Tick Applicable Plan Option)

Limit (Per Tyre/Alloy)(Required)

Term Selection(Required)

RTT24L1000

RTT24L2000

RTT24L3000

RTT24L4000

RTT24L5000

RTT36L1000

RTT36L2000

RTT36L3000

RTT36L4000

RTT36L5000

RTT42L1000

RTT42L2000

RTT42L3000

RTT42L4000

RTT42L5000

RTT48L1000

RTT48L2000

RTT48L3000

RTT48L4000

RTT48L5000

RTT54L1000

RTT54L2000

RTT54L3000

RTT54L4000

RTT54L5000

RTT60L1000

RTT60L2000

RTT60L3000

RTT60L4000

RTT60L5000

RTT72L1000

RTT72L2000

RTT72L3000

RTT72L4000

RTT72L5000

	Term
Limit (Per Tyre/Alloy)	24	36	42	48	54	60	72
N$ 1000	RTT24L1000	RTT36L1000	RTT42L1000	RTT48L1000	RTT54L1000	RTT60L1000	RTT72L1000
N$ 2000	RTT24L2000	RTT36L2000	RTT42L2000	RTT48L2000	RTT54L2000	RTT60L2000	RTT72L2000
N$ 3000	RTT24L3000	RTT36L3000	RTT42L3000	RTT48L3000	RTT54L3000	RTT60L3000	RTT72L3000
N$ 4000	RTT24L4000	RTT36L4000	RTT42L4000	RTT48L4000	RTT54L4000	RTT60L4000	RTT72L4000
N$ 5000	RTT24L5000	RTT36L5000	RTT42L5000	RTT48L5000	RTT54L5000	RTT60L5000	RTT72L5000

Note:
• This is not an insurance product but a redeemable plan on presentation of a valid agreement number
• As the customer, you will be responsible for the payment of repairs or restoration work completed by the repairer that falls outside the scope of this agreement

Customer Declaration (Compulsory):

Any Pre-Existing Damage? (E.g. Tyre Puncture, Left Front Wheel Alloy Scratch)