Commission Consent Disclosure Form

Please ensure you read the Legislative Update On Your Insurance Programme – Important Information by clicking the dropdown arrow before completing this form.

*MUST READ - Legislative Update on your Insurance Programme - Important Information

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Provide Consent: By Ticking this box, I acknowledge that I have read and understood the above disclosures and agree to the commission being paid to the broker.*

Yes

I acknowledge the above as the Insured or if not the Insured, do so with the authorisation of the Insured to provide this consent on their behalf.*

Yes

Print Name*

Date Declared*

Contact Number*

Email Address*