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
 
MEDICALCLAIMS 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
 
 
 
 
NO OBLIGATION QUOTATION FORM
QUOTATION FOR MEDICAL SCHEME
Kindly quote me on a the medical scheme promotion by Liberty Life for individuals, with no obligation, on the details supplied below:
 
Full Name & Surname
Identification Number
Date of Birth
Full Name & Surname of Spouse
Date of Birth of spouse
Names of Children
Date of Births of Children
Current Medical Conditions & General Information
Cronical Medication
Address:
Street Name
Suburb
Town
Province
Contact Number (work)
Contact number (home)
Cell Number
Email Address
Current Medical Scheme Membership Number, if applicable
Broker Code
Your Requirements, such as Full Medical/Hospital Plan/etc & other Remarks
By submitting this form I hereby request a quotation for a Medical Scheme, agree that De Villiers may contact me regarding the requested quote and understand that I am under no obligation to accept the quote. I also understand that the quote may change due to factors like change in health from date of quote to date of joining the scheme.