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)
Email(Required)
Effective Date of Appointment

Intermediary Details

Name & Surname

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.

Consent(Required)