MAIN MEMBER INFORMATION
1

Main
Member

2

Additional
Members

3

Vehicles
Information

4

Additional
Details

5

Select
Services

6

Payment
Details

7

Confirm
Services

Personal Information

* REQUIRED FIELDS
Would you like to receive a monthly newsletter and be notified of specials and new product offerings?
Protect Me is an on-demand mobile response security solution.

Medical Information

Wristband Identification

YOUR PREFERENCE OF WRISTBAND:
Only one wristband per person allowed. Please choose between woven, clip and rubber wristband. Measurements apply only to rubber wristband.
Woven - R48.00
Blue Outside
Yellow Inside
Black Outside
Yellow Inside
Woven-clip - R58.00
Blue Outside
Yellow Inside
Black Outside
Yellow Inside
Rubber - R65.00
VERY IMPORTANT: Please measure wrist and order the next available size
Blue Inside
and Outside
 
 
 
 
 
 
 
Rubber Elite - R325.00
Purple
Dark Blue
Yellow
Green
Pink
Black
White
Red
Rubber Elite Pinstripe - R350.00
Black with
red pinstripe
Black with
blue pinstripe
Black with
green pinstripe
Pink with
white pinstripe
Black with
white pinstripe
 
Additional
members
Remove

Personal Information

Would you like to receive a monthly newsletter and be notified of specials and new product offerings?
Protect Me is an on-demand mobile response security solution.

Medical Information

Wristband Identification

YOUR PREFERENCE OF WRISTBAND:
Only one wristband per person allowed. Please choose between woven, clip and rubber wristband. Measurements apply only to rubber wristband.
Woven - R48.00
Blue Outside
Yellow Inside
Black Outside
Yellow Inside
Woven-clip - R58.00
Blue Outside
Yellow Inside
Black Outside
Yellow Inside
Rubber - R65.00
VERY IMPORTANT: Please measure wrist and order the next available size
Blue Inside
and Outside
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rubber Elite - R325.00
Purple
Dark Blue
Yellow
Green
Pink
Black
White
Red
Rubber Elite Pinstripe - R350.00
Black with
red pinstripe
Black with
blue pinstripe
Black with
green pinstripe
Pink with
white pinstripe
Black with
white pinstripe
 
Main
Member
Vehicle
Information
Remove
VEHICLE INFORMATION (Roadside Assistance R59 per month per vehicle)
Please note: Vehicle refers to motor vehicle, trailer or caravan. Only vehicles marked YES for roadside assistance will be eligible for roadside assistance benefits. Vehicles marked NO will only be listed for information purposes.

Vehicle Information

Additional
Members
Additional
Details
Vehicle
Information
Select
Service
Select the services that you need below

Alpha Service

ALPHA PACKAGE (Compulsory)
@ R139 / Month
R139.00

Dependants

Vehicles

Additional Services

HOUSEHOLD ASSISTANCE i
@ R51 / Month
R0.00
TAKE ME HOME i
@ R68 / Month
R0.00

Total Monthly Premium

R

PET TAGS
@ R30.00 / Tag
R0.00
COLLECT WRISTBANDS
Collect from MONUMENT PARK Offices
R0.00
COURIER WRISTBANDS
ADMIN FEE
1

Total Once-Off Cost

R

TOTAL FIRST MONTH

R

NOTE: The above cost will be a once-off cost that will be deducted via debit order or credit card during the first-month payment and not again thereafter.

TOTAL MONTHLY COST THEREAFTER

R

Additional
Details
Account
Details
Please indicate your preferred payment method below:
DEBIT ORDER
NOTE:
WE WILL CONFIRM DEBIT ORDER PER
TELEPHONE WITH YOU
CREDIT CARD
NOTE:
FOR SECURITY REASONS
WE WILL CONTACT YOU TO VERIFY YOUR CREDIT CARD DETAILS
Account
Details
Confirm
Services
ALPHA PACKAGE
@ R139.00 / Month
R139.00
DEPENDANTS
@ R69.00 / Month / Person
0
RR0.00
PROTECT ME
@ R31.00 / Month / Person
0
R0.00
ROADSIDE ASSISTANCE
@ R59.00 / Month / Vehicle
0
RR0.00
HOUSEHOLD ASSISTANCE
@ R51.00 / Month / Person
R0.00
TAKE ME HOME
@ R68.00 / Month
R0.00
TEACHER ON LINE
@ R22.00 / Month
R0.00
TOTAL
R0.00
ADMIN FEE
1
PET TAGS
@ R30.00 / Month / Person
0
R0.00
TOTAL
R0.00
NOTE: The above cost will be a once-off cost that will be deducted via debit order or credit card during the first-month payment and not again thereafter.
Select
Service