Broker Appointment Form

I hereby give consent for MyBenefitz to be appointed as my broker for the following policies:

I, the above mentioned, hereby appoint MyBenefitz, a Juristic Representative of Lebon Consulting (Pty) Ltd ("Lebon") an authorised Financial Services Provider with FSP 52013, to act as my Insurance Broker regarding the policies listed above.

This means that Lebon is appointed as my insurance broker in order to:

• Secure quotations on my behalf from a range of insurers
• Arrange for insurance cover on my behalf after I accept a quotation
• Process any claims on my behalf with my insurer
• Renew my Insurance Cover as and when necessary and only after securing my agreement to do so
• Amend my Insurance cover from time to time as per my request
• Provide me with guidance regarding all my matters of an Insurance nature
• Deal with queries I may have regarding my insurance cover
• Facilitate cancellation of my policies with my consent

In order to fulfil these responsibilities, I authorise, MyBenefitz to obtain, on my behalf and at my request, all relevant information pertaining to my existing insurance cover, including:

• Policy wordings
• Policy schedules
• Endorsements
• Detailed claims experience

I acknowledge and accept that:

• This appointment revokes any previous insurance broker's appointment.
• Lebon is a registered Financial Services Provider with license number 52013 and company registration number 2021/570343/07.
• Lebon does not collect or handle insurance premiums and that these are collected and/or paid directly to the Insurer
• As required in terms of the Financial Advisory and Intermediary Services Act, Lebon has adequate professional indemnity cover
• As a professional organisation, Lebon's liability is limited to R 1 000 000.00 in the annual aggregate
• Signature of this letter of appointment is prima facie evidence that the signatory is authorised to appoint MyBenefitz as my insurance broker
• The termination of this appointment is subject to 30 days written notice.