Intermediary Appointment 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 & 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 AppointmentDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Intermediary DetailsIntermediary (Brokerage)(Required)FSP NumberName & Surname First Name Surname Intermediary Email(Required) Policyholder DeclarationI 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. Consent(Required) I agree to the various declarations above Δ