Vehicle Protection Application

Complete this application for Scratch & Dent Cover, Tyre & Rim Cover, or both. Please ensure that all personal, vehicle and damage information is accurate before submitting.

Wildsure Consulting (Pty) LTD is an authorised Financial Services Provider: FSP 46788

Cover Required

Please select the vehicle protection cover the client is applying for.

Autowin Vehicle Protection Application

Scratch & Dent Cover

Tyre & Rim Cover

Scratch & Dent Cover + Tyre & Rim Cover

Client Personal Details

Please provide the client’s full personal and contact details.

First Name

Last Name

ID Number

Cellphone Number

Alternative Contact Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Vehicle Details

Please complete the vehicle information exactly as it appears on the vehicle documents.

Vehicle Year Model

Vehicle Make

Vehicle Model

Vehicle Registration Number

Vehicle VIN Number

Current Vehicle Mileage / Odometer Reading

Scratch & Dent Details

This section applies to Scratch & Dent Cover. Please disclose any existing damage to the inside or outside of the vehicle.

Are there any existing damages to the vehicle?

Yes

Where is the existing damage?

Please describe the existing vehicle damage

Tyre & Rim Details

This section applies to Tyre & Rim Cover. Please disclose any existing tyre or rim damage and provide the tyre replacement date.

Are there any existing damages to the tyres and/or rims?

Yes

What is damaged?

Tyres

Rims

Both tyres and rims

Please describe the tyre and/or rim damage

Date when the client last replaced their tyres

Approximate mileage since tyres were last replaced

Consent & Declaration

Please read and accept the consent and declaration before submitting the application.

POPIA Consent

I agree and consent to Autowin Panel Beating and Wildsure processing my personal information, vehicle information, uploaded documents and application details for the purpose of vehicle protection cover, quotation assistance, policy application, underwriting, administration, claims support and related communication.

Final Declaration

I confirm that all information supplied in this application is true, accurate and complete. I understand that failure to disclose existing vehicle, tyre or rim damage may affect the outcome of my application or future claims.