Life, Invest and Health broker appointment form

Tell Us About You

All information is kept in strict confidence. If you are acting on another person's behalf, please specify later in the form the details of the person you are representing.

Full Name *

Prefix First Name Last Name

E-mail*

Mobile Number*

Area CodePhone Number

Birth Date*

DayMonthYear

Gender*

MaleFemale

ID number*

Name of person you are representing

Complete if you are representing another person

ID number of person you are representing

How is the person you are representing relating to you?

I hereby give consent to The Financial Services Exchange (Pty) Ltd, trading as Astute, or any other institution providing a mechanism for the transmission of such information, or any other authorised financial services provider, to provide any information relating to:

a. long-term insurance;

b. collective investment schemes;

c. retirement funds;

d. medical scheme;

e. health related products

f. bank accounts and deposits

through Astute, or directly, to the authorised user below:

Authorised user: Daberistic Solutions t/a Daberistic Financial Services

FSP number: 25477

Intermediary: Jen-hao (Kevin) Yeh

Signature*

I/we hereby appoint Jen-hao (Kevin) Yeh as my service consultant on my entire portfolio. I understand and accept that by this appointment all previous intermediaries through whom I effected business no longer represent me.

I confirm that the authorised user will be acting on my/our behalf and I/we hereby waive any right to privacy only for the stated purpose. All information so obtained must be treated as confidential by the authorised user and intermediary and may not be made public in any way wihout my/our written consent.

This consent to obtain information will remain effective until cancelled by me/us in writing.

Signature*

Please take a clear picture of your ID using your phone*

Please take a clear picture of the ID of the person you are representing, using your phone*

Existing Policies?

Please give us as much detail as possible your existing policies, including insurance company name and contract number

Aditional comments or policy to be excluded from appointment

Life, Invest, Health broker appointment form