Survey Form – Refiloe Wealth

Refiloe Wealth PTY LTD Survey Form

Details

Refiloe Wealth PTY LTD is an authorised financial services provider FSP 47031 in partnership with
HOSPERSA wish to create a car and household insurance product that is best suited and exclusive to
HOSPERSA members.

Refiloe Wealth Affinity insurance
scheme/program is
aimed to help HOSPERSA achieve specific business and
economic objectives through consultation, research,
design and delivery of relevant risk management
solutions to the HOSPERSA members and connected
communities
in order to achieve the objective as stated above we kindly request
that you fill in the questionnaire below:

Your Name

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Contact number

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Date of birth

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Do you own a vehicle, value of vehicle

Yes

Clear selection

Do you own property

Yes

Clear selection

Are you currently insured

Yes

Clear selection

Your current insurance premium

Clear selection

Your current insurance premium

Clear selection

Current insurer

Clear selection

Do you prefer to be contacted via phone or do you prefer to conduct your insurance needs at your convenience through our digital platform?

Clear selection

Suggestions on how you wish your insurance to work for you, what product do wish for that
would address your needs?

Clear selection

DECLARATION
INFORMATION SHARING – CONSENT OF INSURED
1. I acknowledge that sharing of insurance information for underwriting and claims purposes
(including credit information) between insurers is in the best interest as it enables insurers to
underwrite policies and assess risks fairly and to reduce the incidence of fraudulent claims with a
view to limiting premiums.
2. I waive my right to privacy with regard to underwriting or claims information (including credit
information) that I provide or that is provided by another person on my behalf in respect of any
insurance policy or claim made or lodged by me. This is on my own behalf as well as on the behalf of
any person I represent in terms of this insurance policy.
3. I acknowledge that the Insurance information provided by me may be stored in the shared
database and used as set out above as well as for any decision pertaining to the continuance of my
policy or the meeting of any claim I may submit.
4. I consent to such information being disclosed to any other insurance company or its agent.
5. I acknowledge that the information may be verified against legally recognised sources or
database.
DECLARATION
I/ we hereby acknowledge that Refiloe Wealth (Pty) Ltd may make an enquiry, where applicable,
to the South African Crime Bureau or their authorised representatives to obtain any information or
detail as being
reported on this claim form.
I/ we hereby declare that the afore going to be true in every respect.