Authority to Quote

Authority to Obtain Insurance Information
To Whom It May Concern,

We/I authorise any current insurer(s) to provide RIB Co Pty Ltd t/as Remingtons Insurance Brokers, Authorised Representative (No 1311726) of SMS Insurance Pty Ltd t/as repX (AFSL No 425573), with all information relating to the insurance policies listed below, including coverage details, premiums and claims history for the past five (5) years.
Details
This authorisation is valid for a period of 90 days from the date of signing, unless withdrawn earlier in writing.

I/We confirm that I am/we are duly authorised to provide this consent.

Kind regards,
Signature*
Date*

DayMonthYear
Date
Sign Name*
Title/Role of the Company Representative*
Client Email*
example@example.com
Broker Email*
Use info@remingtons.com.au if unknown
Should be Empty:

Authority to Obtain Insurance Information