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 Details

Name & Surname(Required)

First Name Surname

ID or Passport number(Required)

Cell Number(Required)

Email(Required)

Enter Email Confirm Email

Cinagi Policy Number(Required)

Effective Date of Appointment

Intermediary Details

Intermediary (Brokerage)(Required)

FSP Number

Name & Surname

First Name Surname

Intermediary Email(Required)

Policyholder Declaration

I hereby confirm that I am duly authorised to appoint the above intermediary and intermediary house to act as intermediary on my behalf as it relates to the policy mentioned above.

I understand that the intermediary will be remunerated for their services.

I confirm that all previous agreements with any intermediary relating to this policy has been terminated and the necessary notice periods served.