Broker Appointment

Representative Verification

Enter the cellphone number registered on your InsureEasy representative profile.

Representative Cellphone Number * This number will be used to identify the representative linked to the appointment.

Client Details

Please provide the details of the person or business appointing InsureEasy Brokers.

Client Name and Surname *

ID Number / Company Name *

Cellphone Number *

Email Address *

Physical Address *

Current Insurance

Tell us about the insurance policy you would like InsureEasy Brokers to assist with.

Current Insurer *

Other Insurer

Current Policy Number *

Current Monthly Premium

Product Type *

Upload Current Policy Schedule Optional. Continue if the schedule is not currently available.

How Can We Assist?

Select the main reason for appointing InsureEasy Brokers.

Review my current insurance Obtain alternative insurance quotations Assist with my existing policy Move my policy to InsureEasy Brokers Review my insurance needs and cover Assist with an insurance claim Other

Please tell us how you would like us to assist

Broker Appointment Mandate

Please review the appointment terms before continuing.

Appointment of InsureEasy Brokers

I hereby appoint InsureEasy Brokers (Pty) Ltd, FSP 53008 as my insurance broker to assist me with my short-term insurance requirements.

I authorise InsureEasy Brokers, where reasonably necessary in providing these services, to:

communicate with my current or prospective insurer;
request relevant policy, underwriting and claims information;
obtain and present insurance quotations;
assist with the placement, servicing and review of my insurance cover;
assist with policy amendments and renewals; and
assist with insurance-related claims administration where applicable.

Important This appointment does not automatically cancel, replace or amend an existing insurance policy. It does not automatically change your insurer, premium, debit order, cover or policy benefits.

I have read and accept the Broker Appointment Mandate.

Client Declaration

I confirm that the information provided in this broker appointment is true and complete to the best of my knowledge.

I understand the purpose of appointing InsureEasy Brokers and consent to my information being processed where reasonably necessary to provide insurance-related services.

I confirm that the information provided is correct and accept the declaration above.

Confirm Your Broker Appointment

Review the information below and sign to confirm your appointment of InsureEasy Brokers.

Client

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Cellphone

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Insurer

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Policy Number

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Product

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Appointment Purpose

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Representative

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Client Signature *

I confirm my appointment of InsureEasy Brokers on the terms set out above.

✓

Broker Appointment Received

Thank you. Your Broker Appointment has been received successfully. InsureEasy Brokers will process your appointment and a copy of your Broker Appointment Mandate will be sent to the email address provided.

Please remember that this appointment does not automatically change or cancel your existing insurance policy.

InsureEasy Brokers

Phone Number

Contact Address

Email Address