Associated Broker

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Join today!

[/vc_column_text][vc_column_text]We understand how busy you are, so we have made it as simple as possible to join Firearms Guardian.

*Policyholders are registered immediately after the application form is completed and submitted. The policyholder will get confirmation via email.[/vc_column_text][/vc_column_inner][/vc_row_inner][divider line_type=”No Line” custom_height=”45″][/vc_column][/vc_row][vc_row type=”in_container” full_screen_row_position=”middle” column_margin=”default” column_direction=”default” column_direction_tablet=”default” column_direction_phone=”default” scene_position=”center” text_color=”dark” text_align=”left” row_border_radius=”none” row_border_radius_applies=”bg” overflow=”visible” advanced_gradient_angle=”0″ overlay_strength=”0.3″ gradient_direction=”left_to_right” shape_divider_position=”bottom” bg_image_animation=”none” gradient_type=”default” shape_type=””][vc_column column_padding=”padding-13-percent” column_padding_tablet=”inherit” column_padding_phone=”padding-1-percent” column_padding_position=”left-right” column_element_direction_desktop=”default” column_element_spacing=”default” desktop_text_alignment=”default” tablet_text_alignment=”default” phone_text_alignment=”default” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_backdrop_filter=”none” column_shadow=”none” column_border_radius=”none” column_link_target=”_self” column_position=”default” advanced_gradient_angle=”0″ gradient_direction=”left_to_right” overlay_strength=”0.3″ width=”1/1″ tablet_width_inherit=”default” animation_type=”default” bg_image_animation=”none” border_type=”simple” column_border_width=”none” column_border_style=”solid” gradient_type=”default”][divider line_type=”No Line” custom_height=”55″][vc_column_text]

Associated Broker sign-up form

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"*" indicates required fields

Step 1 of 2

50%

Step 1: Personal Details

Electronic debit order agreement

Surname*

Name*

ID Number*

Cell Number*

Email Address*

Address*

Street Address Address Line 2

Step 2: Bank Account Details

Please provide your bank account information.

Account Holder*

Bank Name*

Account Number*

Account Type

Current (Cheque)SavingsTransmission

Choose an option of cover*

Select your optionFirearms Guardian - Option 1 : R135.00 p/mFirearms Guardian - Option 2 : R245.00 p/m

Debit Date (Your 1st debit order will be your policy inception)*

1st7th15th25thLast day

Your Firearms Guardian policy will only become active once the first debit premium order is received by the insurer.

Debit Order Authorisation

I hereby request and authorise the Administrator, Insuresense Consultants (Pty) Ltd (Insuresense), or its agent/s, to draw against my bank account as indicated herein each month and to debit my account with the amount equivalent to the premium due by me to Insuresense in respect of the Firearms Guardian policy, until cancelled by me in writing. In the event of an increase of the premium, Insuresense, or its agent/s, have my authority to deduct from my account the increased premium. All such debits against my account shall be treated as though I have signed and done them personally. If, in the event of payment from my bank account, such payment day falls on a Sunday or public holiday, the payment day will automatically be the following ordinary business day.

Agree

Declaration

I hereby apply for a Firearms Guardian policy in accordance with all applicable terms and conditions. I personally completed this application. I acknowledge that payment of premiums on the due dates is my responsibility. I warrant that all information given in this application form is true and complete. I understand and accept the implications of this application and I accept that this application, together with the applicable terms and conditions, represent the agreement between myself and the underwriter of the Firearms Guardian policy, GENRIC Insurance Company Limited (GENRIC). I further understand that the acceptance of my application is in the sole discretion of Insuresense and GENRIC.

Agree

Declaration and informed consent in terms of the Protection of Personal Information Act 4, of 2013 (POPIA)

We at GENRIC Insurance Company Limited (GENRIC) and Insuresense Consultants (Pty) Ltd (Insuresense) respect your right to privacy. We need to collect and process some of your personal information in terms of various Privacy and Data Management laws and are bound by the terms and provisions of the Protection of Personal Information Act, regarding the acquisition, usage, retention, transmission and deletion of your personal information. All information obtained or acquired from /about you shall remain confidential unless you provide written consent, or unless we are required by law to disclose such information. Your personal information collected is for the primary purpose of providing you with insurance cover and for all other activities and processes incidental to and relevant to this purpose. As this information forms the basis of our assessment and terms, we offer you, it must be correct, complete, and up to date. We will always comply with all relevant regulations in dealing with your information and keep it secure and confidential at all times. Your information shall be kept confidential; however, we shall disclose it to certain third parties as required and other insurers for the specific purpose of insurance and to reduce and prevent any form of fraudulent activity. We may disclose your personal information to our service providers who are involved in the delivery of products or services to you. We have agreements in place to ensure that they comply with the privacy requirements as required by the Protection of Personal Information Act. When we contract with third parties, we impose appropriate security, privacy and confidentiality obligations on them to ensure that personal information that we remain responsible for, is kept secure. We will ensure that anyone to whom we pass your personal information agrees to treat your information with the same level of protection as we are obliged to do. We may also disclose your information: 1. Where we have a duty or a right to disclose in terms of law or industry codes; and 2. Where we believe it is necessary to protect our rights. You have the right to ask us to update, correct or delete your personal information. Should you decide not to accept the proposal, the information collected, will be de-identified and only used for statistical and research purposes. Should you decide to cancel this insurance contract you further consent to GENRIC and Insuresense, in retaining the information in line with the legally permitted retention period, for statistical and reporting purposes only. Our Privacy Notice and POPIA Policy provides the details of how we deal with the personal information of our clients, and it is available on our website at the following address: https://www.genric.co.za. I hereby voluntary consent to GENRIC processing my Personal Information. I understand the purposes for which my Personal Information is required and for which it will be used. I give GENRIC permission to process my Personal Information as provided above.

Agree

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