Intermediary Registration, South Africa

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Intermediary Registration Form

(Leisure Vehicle Insurance - Sales)

MUST BE COMPLETED AND SIGNED BY THE INTERMEDIARY, PLEASE COMPLETE ALL SECTIONS IN BLOCK LETTERS

COMPANY

Name of Company*

Branch/Town/City*

INTERMEDIARY DETAILS

First name*

Surname*

Cellular*

Date of Birth*

Age*

eMail*

Qualifications

Are you FAIS Compliant? If ‘YES’ FSP Number

Hobbies/Interests

Spouse

First name

Date of Birth

Child

First name

Date of Birth

Child

First name

Date of Birth

Child

First name

Date of Birth

Child

First name

Date of Birth

BANK DETAILS

Bank*

Branch

Branch Code

Account Number*

Name of Account Holder*

CARA-SURE INTERMEDIARY
CONDITIONS AND LIMITATIONS

PLEASE MAKE SURE THAT YOU READ EACH ITEM BELOW AND WE ACCEPT THAT YOU HAVE READ AND UNDERSTOOD THE CONTENTS WHEN THIS DOCUMENT IS SUBMITTED

I understand that if I am not FAIS Compliant, I may NOT under NO circumstances whatsoever provide any ADVISE to any person/s on behalf of or regarding the CaraSure product.
If you are NOT FAIS Compliant, you may ONLY provide INFORMATION and NO ADVISE. (“Information” regarding CaraSure product ONLY)
Only once I am Registered with CaraSure, received the necessary Training as provided by CaraSure and accepted as an Intermediary with CaraSure as well as being FAIS Complaint, may I provide ADVISE to a client.
I undertake that any Information/Advise I give to a client will be honest, without misrepresenting CaraSure or the Insurance Industry.
I further understand that I will NOT receive ANY commission from Natsure (Pty) Ltd/CaraSure if I am not FAIS Complaint and Registered with the FSCA (Formerly ‘FSB’).

Signature*

First name and Surname*

Date*

Intermediary Registration

Intermediary Registration Form

COMPANY

INTERMEDIARY DETAILS

BANK DETAILS

CARA-SURE INTERMEDIARYCONDITIONS AND LIMITATIONS

CARA-SURE INTERMEDIARY
CONDITIONS AND LIMITATIONS