BROKERS LETTER OF APPOINTMENT

I/We the undersigned hereby appoint Albert Lombaard of Lombkor cc as my /

our broker and authorise the transfer of the following policies:

BROKER CODE –

POLICY TYPE & NUMBER: …………………………………………

…………………………………………

The Broker is hereby authorised to handle all matters arising including

placements, amendments or claims and if required to nominate new insurers.
It is agreed that the broker is entitled to receive commission from the insurers.

NAME AND ADDRESS OF INSURED

………………………………………….

………………………………………….

ID NUMBER: …………………………………

TEL NO: ……………………… CELL NO: ………………………………

FAX NO: ………………………………

SIGNITURE: …………………………........ DATE: ……………………

Tel: 044 382 6008 | Fax: 044 382 0040 | Cell: 082 8828 159 | info@lombkor.co.za
12 Pledge Square, Main Street, Knysna, 6571, Western Cape, South Africa