Note of Authorisation

(Brokers Note)
Metropolitan Head Office
PO Box 2212
Bellville
7535
Tel. (021) 940-5911
Fax To:
Fax No.

Option 1: Policy Information

I, . (Initials & surname) with ID no.
(or date of birth), hereby grant permission to intermediary
(Commission & debit no)/ to obtain the policy information of my insurance
portfolio on my behalf, effective from. /./. until. /../. .
OR
Option 2: Policy Information & Appointment of Intermediary
I, . (Initials & surname) with ID no.
(Or date of birth), hereby grant permission to intermediary
(Commission & debit no)/ to obtain the policy information of my insurance
portfolio on my behalf, effective. /./. until ././. and serve as my new intermediary.

Company

_________________________
Client Signature

Policy Number(s) if known

_____________________
Date

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Full Name(s) & Surname