CONTACT DETAILS
 
PHYSICAL ADDRESS
28 Du Plessisstraat
Schweizer-Reneke
2780
 
CONTACT NUMBERS
053-963-2845
053-963-2846
 
FAX NUMBER
053-963-2860
 
CONTACT PERSONS
Jan de Villiers
Contact Number
082-524-8733
devilliersmakelaars@telkomsa.net
 
Marinda de Villiers
Contact number
082-524-8744
marindadevilliers@telkomsa.net
 
CLAIMS
Contact Person
 
Contact Number
 
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
Medical Scheme Membership Number
Company
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.