Client Consent Form

Please fill in the form below

I, (required)

Identity Number:(required)

Address:(required)

Contact details:

E-mail Address:(required)

hereby authorize SANET HORAK (or assistants)- Identity Number: 691003 0042 083

To obtain information on my behalf regarding my insurance with any assurer/financial institute/insurance company, ie:
• Policy information
• Claims history
• Current Premium computation

This authorization is granted until it is revoked in writing.

TO CONFIRM:(required)
Please tick this checkbox 

DATE:(required)

INSURER:(required)

POLICY NUMBER:(required)