CONTACT DETAILS
 
PHYSICAL ADDRESS
28 Du Plessisstraat
Schweizer-Reneke
2780
 
CONTACT NUMBERS
053-963-2845
053-963-2846
 
FAX NUMBER
053-963-2860
 
BROKERS: INSURANCE/INVESTMENTS
Jan de Villiers
Contact Number
082-524-8733
devilliersmakelaars@telkomsa.net
BROKERS:MEDICAL SCHEMES/FUNERAL PLANS
Marinda de Villiers
Contact number
082-524-8744
marindadevilliers@telkomsa.net
 
MEDICAL CLAIMS DEPARTMENT
Contact Person
Anne Koorts
Contact Number
053-963-2845
devilliersmakelaars@telkomsa.net
 
CUSTOMER SUPPORT
Contact Person
Marinda de Villiers
Contact Number
082-524-8744
devilliersmakelaars@telkomsa.net
 
 
APPOINTMENT OF BROKER
PERMISSION TO OBTAIN PERSONAL INFORMATION
I hereby authorize you to provide full information of my policies with you to De Villiers Makelaars (De Villiers & Hoffman Makelaars bk h/a ck99/66082/23) and appoint them as my broker.
 
Full Name & Surname
Identification Number
Date of Birth
Address:
Street Name
Suburb
Town
Province
Contact Number (work)
Contact number (home)
Cell Number
Email Address
Medical Scheme Membership Number
Company
Other Companies(Specify)
Broker Code
Additional Information or Remarks
By submitting this form I hereby appoint De Villiers Brokers as my Broker for Membership mentioned above.  I further more accept this form to be legally binding.