Authorization to release Information

Dear Sir/Madam, I

NB: as Insurance

ID Number:

In my capacity as

Registrations No:

Consent:

hereby authorise your organisation to release information relating to my insurance portfolio to Shomang Brokers, FSP No 43118.
The contact person for Shomang Brokers is Mosidi Shomang on +27 (011) 452 4662 or 083 800 8693 or email: mosidi@shomanggroup.co.za

Insurance Company

Policy Number

Insurance Company (copy)

To enable the Insurers to underwrite risk fairly, I give consent to Shomang Brokers, and the Insurers requested by them in verifying and share my personal or company policy information with other Insurers and institutions as well as access to my personal or company credit information held by other institutions.
Regards

Policyholder Signature:

Clear Signature

Date:

Address

Email Address

Postal Code

Telephone

Cell Phone

NB:

““We will share your personal information with other insurers. This includes information about your insurance, claims and premium payments. We do this to provide insurance services.
We will treat your personal information with caution and have put reasonable security measures in place to protect it. Shomang Brokers will not, without your express consent, use your information for any purpose other than as set out above”.
Broker Appointment: Health Profession
Version 01
Page 1 of 1
SB-S042
Date reviewed: March 2025
© FSP Licence No: 43118