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APPOINTMENT OF BROKERS

Selah Brokers PTY LTD
53 York Street
George

Tel: 044 873 0735
Fax: 044 873 2350

The Manager



REGARDING: APPOINTMENT OF BROKERS

I/We
ID. NUMBER:

Hereby appoint Selah Brokers (FSP 45456) as my/our broker to arrange , manage and maintain my/our portfolio of insurance as mutually agreed upon.

POLICY NUMBER/S:
LYONESS MEMBERSHIP NUMBER:
I/We accept that,
Contact Number:
Email Address:  
Address: line 1
Address: line 2
Address: line 3
Postal Address:  

Effective Date of appointment :

 

___________________________________
SIGNATURE OF INSURED
______________________
DATE SIGNED

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Selah is an authorised service provider. FSP License: 45456 - Administration by Sapcor Broking Solutions.    

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