When completed please return to Elrine Eckert (elrine@visionbrokers.co.za)
POLICY INFORMATION ONLY

I, the undersigned
(Full names & Surname)

(Business name if applicable)

Client Landline:

(ID Number / Company/CC)

Client email:

Client Cell Phone:

Hereby grant permission to intermediary and/or broker Vision Insurance to obtain all the policy information - complete portfolio of policies (latest schedules reflecting premiums, excess structures, extensions and all cover) full claims history (claims dates, claim type and amounts) and all other relevant details regarding my full insurance portfolio, on my behalf
I also hereby give permission for the sharing of all personal & policy information (current or old) to gather claims history, run ITC credit scoring as regulated by the Protection of Personal Information Act in order to act on the instructions given by me/us (insured)
*Please note that no information may be withheld, altered or deleted on the schedules provided as per the FAIS ACT.

Date:

Policy numbers

Insurer

Agency number

*Please provide All short term insurance policies pertaining to the client
Policy Owner / Authorized Person

Date:

STATUTORY DISCLOSURE

Disclosure of information
We may disclose your personal information to our service providers who are involved in the delivery of products or services to you. We have agreements in place to ensure that they comply with the privacy requirements as required by the Protection of Personal Information Act.

We may also disclose your information:
• Where we have a duty or a right to disclose in terms of law or industry codes;
• Where we believe it is necessary to protect our rights.

When we contract with third parties, we impose appropriate security, privacy and confidentiality obligations on them to ensure that personal information that we remain responsible for, is kept secure.

We will ensure that anyone to whom we pass your personal information agrees to treat your information with the same level of protection as we are obliged to.

Correction of your information
You have the right to ask us to update, correct or delete your personal information. We will require a copy of your ID document to confirm your identity before making changes to personal information we may hold about you. We would appreciate it if you would keep your personal information accurate.

Consent
I have read and understood the term of the above disclosure and in terms of Protection of Personal Information Act of 2013 by signing this Mandate/ Letter of Authority I consent to continue the sharing of my personal information for purposes of this and future similar transactions.

I consent to Statutory Disclosure and POPIA Date:

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