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Broker appointment form.mdi


									               Authorisation to Change / Appoint Intermediary
Attention:                                                     Date:

Fax number:

Member Details
Surname:                                                       Initial(s):

Identity Number:                                               Date of Birth:

E-mail:                                                        Tel. Number:

PPS Membership No.:                                            Profmed Membership No.:

I understand and accept that by this appointment all previous Intermediaries, with whom business was affected with
PPS Insurance Company Limited, will no longer represent me.

I hereby request that the PPS records be amended to reflect the below mentioned Intermediary in respect of the
following Products :
          PPS Products

          PPS Retirement Annuity

          Profmed Medical Scheme
          All of the above

Intermediary Details
Surname:                                                        Initial(s):

Identity Number:                                               Stakeholder Number:

Telephone Number:                                              E-mail adress:

Effective Date of change :

Signed at                                     on the                     day of                     20

Client’s signature                                              Intermediary’s signature

                          PPS is an authorised Financial Service Provider - Licence 1044
          E-mail: Website: Head Office Tel: (011)6444200 Fax: (011)6444400

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