BROKER AUTHORISATION FORM

TO WHOM IT MAY CONCERN THIS IS TO CONFIRM THAT MR DANY DUPREZ HAS MY PERMISSION TO OBTAIN ANY INFORMATION HE MAY REQUIRE IN RESPECT OF ANY LIFE AND SHORT TERM POLICIES AND OR INVESTMENTS THAT I HAVE WITH ANY INSURANCE,ASSURANCE OR INVESTMENT COMPANY. NAME ADDRESS TEL NR (HOME) TEL NR (WORK) ID NR DATE SIGNATURE