Intermediary Appointment The purpose of this form is to change the appointed intermediary on your existing Cinagi policy. On changing the intermediary the new intermediary will have access to all your policy information while also being remunerated for any intermediary services rendered. Personal DetailsName(Required) First Last ID Number(Required)Policy Number(Required)Email(Required) Member Cell Number(Required)Date from which the appointment applies(Required)Intermediary DetailsIntermediary(Brokerage)(Required)Brokerage FSP Number(Required)Advisor Name(Required) Name Middle Surname Email(Required) Cell Number Δ
