CLIENT DETAILS

Please fill out the below mentioned client details to ensure appropriate personal information is obtained for risk purposes.

SHARING OF INSURANCE INFORMATION

Your authorisation to Lionel Isaacs Insurance Brokers (Pty) Ltd as well as mandated insurance companies:

1. I acknowledge that the sharing of information for underwriting and claims purposes is in the public interest, as it will enable insurers to underwrite policies and assess risks fairly and to reduce the incidence of fraudulent claims with a view to limiting premiums.
2. On my behalf and on behalf of any person I represent herein, I hereby waive my right to privacy with regard to any underwriting and claims information in respect of any insurance policy or claim made or lodged by me, or on my behalf.
3. I consent to such information being stored in the shared database and used as set out above
4. I also consent to such information being disclosed to any Insurer or its agent.
5. I further consent to any underwriting information being verified against legally recognised sources or databases.

DISCLOSURE NOTICE

LIIB is a registered Financial Services Provider (FSP #13343) as a short-term insurance broker.

LIIB earns a binder fee of 3.5% on the premium as well as commission of 20% for every iTOO [MY]CYlution Cyber Insurance policy placed on risk by way of a binder agreement entered into with The Hollard Insurance Company.

LIIB levies an operations fee for risk and claims advice and service, as more fully set out in our comprehensive Guide to Financial Services (a copy of which is available on request). This operations fee also includes a recovery for certain costs related to acting as your independent intermediary, including training, information technology expenditure, audit costs and compliance expenditure. The relevant operations fee is fully disclosed in the policy documentation and/or schedule.

DECLARATION

I hereby warrant that the details contained in the above particulars and statements are true and contain all information known to me affecting the risks insured and that this and any other statement made by me or on my behalf for the purpose of the proposed insurance shall be the basis of and incorporated in the contract between me and the insurer.

In order to provide you with insurance, we have to process your personal information. We will share your personal information with other insurers, industry bodies, credit agencies and service providers. This includes information about your insurance, claims and premium payments. We do this to provide insurance services, prevent fraud, assess claims and conduct surveys. We will treat your personal information with caution and have put reasonable security measures in place to protect it. By submitting this form, you agree to the processing and sharing of your personal information. Please refer to our Privacy Policy available at www.liib.co.za.

It is important that you should disclose all material facts, that is, those facts that would influence an insurer in the acceptance or assessment of your proposal. Failure to disclose such facts may result in claims not being met. If you are in any doubt about whether a fact is material you should disclose it. You should keep a record (including copies of letters) of all information supplied to us for the purpose of entering into this contract.

CONFIRMATION OF CONSENT