Appointment of brokers

Dear Sir/Madam, I

ID Number:

In my capacity as

Registrations No:

Insurance Company

Policy Number

Insurance Company (copy)

Consent:

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.
Shomang Brokers contact person is Mosidi Shomang on +27 (011) 452 4662 or 083 800 8693 or email: mosidi@shomanggroup.co.za
The appointment is with immediate effect. Regards

Policyholder Signature:

Clear Signature

Date:

Address

Address Policy Registrations

Postal Code

Email Address

Cell Phone

Telephone

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