Client Application A trusted partner committed to your insurance premium financing Client Application – CarrotPay Premium Financing CarrotPay Premium Finance Client Application Application Type Customer Category Individual Family Club / Association Corporate / SME New or Renewal Policy NewRenewal Customer Information – Individual Full Name Date of Birth GenderMaleFemale Phone Email Residential Address Insurance Policy Details Insurance TypeMotorHealthLifeTravelMarineFire / PropertyGroupOther Insurance Provider / Underwriter Broker (if applicable) Policy Start Date Policy End Date Do you have a quotation?NoYes Quotation Reference Upload Quotation Premium & Financing Total Premium Down Payment Financing Amount Tenure3 Months6 Months9 Months12 Months Repayment FrequencyMonthlyQuarterly Bank Details & Debit Authorisation Bank Account Name Account Number Debit AuthorisationSelectYes – I authorise debits per repayment schedule Uploads Valid ID Proof of Address CAC Docs Board Resolution Declarations & Consents Truth & Accuracy DeclarationSelectYes Consent to Credit Checks & VerificationSelectYes Accept Terms & Privacy PolicySelectYes Save Draft Submit Application Δ
