registration form - broker directory broker... · 2018-04-29 · this signed authority and mandate...
TRANSCRIPT
BASIC INFORMATION:
Country:
Province:
City:
Suburb:
Title (Business Name)
URL (Website Adress)
Street Adress:
Postal Adress:
Code:
FSB License Number:
BEE Rating:
Business Telephone:
Business Fax:
Business Afterhours:
Business email:
Any Other Information:
REGISTRATION FORM
Web Directories
Email: [email protected]
Office: +27 (0) 12 403 0120 / Fax: 086 759 2532
PO Box 11976, Queenswood, Pretoria, 0121
Website: www.brokerdirectory.co.za
Page 1/7
CONTACT PERSONS FOR PUBLICATION:
INSERT CONTACT PERSON
Contact Person:
Designation:
Phone:
Email:
INSERT CONTACT PERSON
Contact Person:
Designation:
Phone:
Email:
INSERT CONTACT PERSON
Contact Person:
Designation:
Phone:
Email:
INSERT CONTACT PERSON
Contact Person:
Designation:
Phone:
Email:
INSERT CONTACT PERSON
Contact Person:
Designation:
Phone:
Email:
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PERSON RESPONSIBLE FOR FINANCE & ADMINISTRATION:
INSERT CONTACT PERSON
Contact Person:
Designation:
Phone:
Email:
SHORT TERM INSURANCE
AA Insurance Services JDG MICRO INSURE
ABSA DIRECT KING PRICE INSURANCE
ABSA INSURANCE RISK MANAGEMENT KINGFISHER
ACE INSURANCE LIMITED KHULA CREDIT GUARENTEE
AECI CAPTIVE INSURANCE COMPANY LANDMARK INSURANCE
AFRICA REINSURANCE CORPORATION LEGALWISE - LEGAL EXPENSES INSURANCE
AIG SOUTH AFRICA LION OF AFRICA
ALEXANDER FORBES LLOYDS INSURANCE
ALIANZ GLOBAL CORPORATE & SPECIALITY MARSH INSURANCE
AON SOUTH AFRICA MI WAY
AUTO & GENERAL MMELA
BIDVEST INSURANCE MOMENTUM
BoE PRIVATE CLIENTS MUA
BOTSWANA INSURANCE MUTUAL AND FEDERAL
BROLINK NATSURE
BUDGET INSURANCE NEDCOR
CENTRIQ INSURANCE NEW NATIONAL ASSURANCE
CIB INSURANCE ADMINISTRATORS OAKHURST
COFACE SOUTH AFRICA INSURANCE ONE INSURANCE
COMPASS INSURANCE ORICO
CONSTANTIA INSURANCE OUTSURANCE
CORPORATE GUARENTEE SA PENDING
CREDIT GUARENTEE INSURANCE PINNAFRICA
CTU CLAREDON TRANSPORT UNDERWRITERS PSG INSURANCE
DIAL DIRECT INSURANCE QUICKSURE
DIRECT AXIS INSURANCE RAND MUTUAL
DISCOVERY INSURE LIMITED REGENT
EMERALD INSURANCE RENASA
EMERITUS REINSURANCE RMB
ENPET AFRICA INSURANCE CORPORATION SA HOMELOANS
ETANA INSURANCE - HOLLARD SA UNDERWRITERS
EXPORT CREDIT INSURANCE SAFIRE
FIRST FOR WOMEN INSURANCE SANTAM
FNB INSURANCE SASRIA
FSP SOLUTIONS SAXUM
G4S INSURANCE SCOR AFRICA
GENERAL REINSURANCE AFRICA SMART INSURANCE
GLENRAND MIB STANBIC
Guard Risk TELESURE
HANNOVER RE AFRICA UNITRANS
HDI GERLING INSURANCE UNITY
HOLLARD INSURANCE LIMITED VIRGIN
HOME LOAN GUARANTEE COMPANY NPC VIRSEKER
I WYZE (Old Mutual) WESTERN UNION
IEMAS FINANCIAL SERVICES WORKERS LIFE
INDEQUITY SPECIALISED INSURANCE XL INSURANCE CO
INDWE RISK SERVICES ZURICH
INFINITI INSURANCE LIMITED
INNOVATION GROUP
INTEGRISURE
INTERMEDIARIES GUARANTEE FACILITY Page 3/7
LIFE INSURERS
1 LIFE INSURANCE LIMITED
ABSA LIFE
AFRICAN UNITY INSURANCE LIMITED
AIG LIFE SOUTH AFRICA
ALEXANDER FORBES LIFE
ALLAN GRAY LIFE
ASSUPOL LIFE
AVBOB MUTUAL ASSURANCE SOCIETY
BIDVEST LIFE
BOPHELO LIFE BENEFIT SERVICES
CADIZ LIFE
CENTRIQ LIFE INSURANCE COMPANY
CHANNEL LIFE LIMITED
CITADEL LIFE
CLIENTELE LIFE ASSURANCE COMPANY
CONSTANTIA LIFE & HEALTH ASSURANCE
CORONATION LIFE ASSURANCE COMPANY
DISCOVERY LIFE
FEDGROUP LIFE LIMITED
FEMA
FIRSTRAND LIFE ASSSURANCE LIMITED
FRANK.NET LIFE LIMITED
GUARDRISK LIFE LIMITED
HANNOVER LIFE AFRICA
HOLLARD LIFE ASSURANCE COMPANY
INVESTEC ASSURANCE
INVESTMENT SOLUTIONS
JDG MICRO LIFE
METROPOLITAN LIFE
MOMENTUM LIFE
NEDGROUP LIFE
NESTLIFE ASSURANCE
NETCARE LIFE
NEW ERA LIFE
OASIS CRESCENT
OLD MUTUAL LIFE
PRESCIENT LIFE
PROFESSIONAL PROVIDENT SOCIETY -
PPS PRUDENTIAL
PSG LIFE
REGENT LIFE
RGA REINSURANCE
RMA LIFE
RMB STRUCTURED LIFE
SAFRICAN
SANLAM LIFE
STANDARD GENERAL
STANLIB
STRATEGIC INVESTMENT SERVICE LIFE
SWISS RE LIFE AND HEALTH AFRICA
SYGNIA LIFE
UNION LIFE LIMITED
VIVA LIFE INSURANCE LIMITED
VODACOM LIFE
WORKERS LIFE ASSURANCE COMPANY
ZURICH LIFE SA
KGA LEWENS BEPERK
LAND BANK LIFE INSURANCE LIMITED
LIBERTY LIFE GROUP LIMITED
LION OF AFRICA LIFE ASSURANCE
LOMBARD LIFE INSURANCE COMPANY
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FEMAKingFisher
CAR & HOME INSURANCE LIFE & MEDICAL
ART AND COLLECTABLES INSURANCE
BUILDING INSURANCE
CAR / VEHICLE TRACKING
CAR INSURANCE
CARAVAN INSURANCE
HOUSEHOLD CONTENT INSURANCE
LEGAL AID INSURANCE
MARINE AND BOAT INSURANCE
MOBILE DEVICE INSURANCE
MOTORCYCLE INSURANCE
MOUNTAIN BIKE INSURANCE
PET INSURANCE
POTHOLE INSURANCE
ROAD BICYCLE INSURANCE
CREDIT LIFE INSURANCE COVER
DIABILITY INSURANCE
EMERGENCY SERVICES
FINANCIAL PLANNING
FUNERAL COVER
HOSPITAL PLAN
IDENTITY THEFT
KEYMAN INSURANCE
LIFE INSURANCE COVER
MEDICAL AID
MEDICAL INSURANCE
ROAD ACCIDENT INSURANCE
SALLARY PROTECTION
SERIOUS ILLNESS COVER
SCRATCH AND DENT INSURANCE
INVESTMENT
SMALL HOLDINGS INSURANCE
TRAVEL INSURANCE
VIDEO & PHOTOGRAFIC EQUIPMENT
FINANCIAL PLANNING VINTAGE VEHICLE INSURANCE
BUSINESS INSURANCE
AGRICULTURAL INSURANCE
ANIMALS & LIVESTOCK INSURANCE
APRAISORS & EVALUATORS
AVIATION INSURANCE
BUILDINGS AND PREMISES INSURANCE
CASH IN TRANSIT INSURANCE COVER
EMPLOYEE BENEFITS
ENGINEERING INSURANCE
ENVIROMENT HAZMAT COVER
FIRE INSURANCE
FUEL RETAILER INSURANCE
HOSPITALITY INDUSTRY INSURANCE
IN TRANSIT - TRANSPORT INSURANCE
KEYMAN INSURANCE
MARINE AND BOAT INSURANCE
MUNICIPAL INSURANCE
OWNER DRIVER SCHEMES
PUBLIC LIABILITY INSURANCE
TAXI INSURANCE
TRAVE INSURANCE
TRUCK INSURANCE
VEHICLE TRACKING
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ASSET MANAGEMENT
ANY OTHER SERVICES
FOREXSAVING PLANSTAX CONSULTINGUNIT TRUST
GROUP SCHEMESTESTAMENT / WILL
PROFFESIONAL INDEMNITY
•SMASH-PRO (Pty) Ltd t/a WEB DIRECTORIES • Regno: 2013/005016/07 • VAT No: 4200267682• PO BOX 11976, Queenswood, 0121 • +27 (0)12 403 0120 or +27 (0) 713371635
Revised:14 April 2015
BUSINESS NAME: CLIENT NUMBER: (Office Admin)
We welcome you as a valued client on the Web Directories!
We are ready to ensure that your business benefit continuously from increased customer service delivery and the leverage power of the WEB to direct new customers to your doorstep - unlocking business opportunities for your business!
To enable us to deliver accurate and swift service , we ask that you please help us to conclude this easy registration process – it is also required by SA Bank rules
Check on-line @ the applicable URL provided below that your application data was captured correctly
Sign this mandate and mail or fax a copy to:
o E-mail: [email protected] Fax: 086 759 2532
AGREEMENT
Implementation of this agreement is subject to client’s approval of the Information to be inserted and hosted on the applicable business page in the Agreed Directory /s. The client accepts full responsibility for information displayed, specifically relating to Industry Contracts & Endorsements.
WEB DIRECTORIES AGREES TO:o Host and promote the client’s information on the web based database/s in the standard format as displayed on the chosen
Directory – please indicate with mark in the applicable tick box/es:
(A) PANELBEATERS DIRECTORY - http://www.panelbeatersdirectory.co.za
(B) TOWING DIRECTORY - http://www.towingdirectory.co.za
(C) BROKER DIRECTORY - http://www.brokerdirectory.co.za
(D) AUTO REPAIR DIRECTORY - http://www.autorepairdirectory.co.za
o Initialize & update such information from time to time, as & when requested to do so
THE CLIENT AGREES TO:
o Supply accurate information in the format requested & continuously check the info displayed on the relevant page/s to becorrect – specifically regarding contractual agreements and endorsements
o Payment of the agreed service fee in advance. Amount/s as indicated below (All amounts indicated is VAT Excluded)
Monthly Debit order or EFT: (A) +(B) +(C) +(D) =TOTAL
Annual cash collection or EFT: (A) +(B) +(C) +(D) =TOTAL
Once of Design & Programming Fee of R 200 per Business Page. Number x R200 =TOTAL
= TOTAL FIRST MONTH D/O: + VAT = MONTHLY THEREAFTER: (VAT Incl.)
OR TOTAL ANNUAL DUE : + VAT = Page 6/7
o If payment for services is to be done via EFT it should be made to the following company bank account
Smashpro FNB Pinnacle Branch Code: 250016 Account No: 62393019396 Reference: Client number. Proof of Payment: to [email protected] Banking details also available on Invoice documentation
RENEWAL & CANCELLATION: o Monthly agreements - automatic renewed monthly, on a continuous basis. Cancellation with one(1) calendar month’s written
notice o Annual agreements – deemed to automatically renew annually on anniversary date, unless a cancellation notice is received
with one (1) calendar month’s written notice. o Change in membership fees (if any) communicated to the client’s nominated e-mail address:
Month-to-month agreements: one (1) calendar month Annual contracts : one (1) calendar month before annual renewal date
BANK DEBIT ORDER INSTRUCTION
NAME (Business Name - Debtor) : ADDRESS: CONTACT PERSON: CONTACT PERSON – E-MAIL:
DEBIT AMOUNT (in advanced – Excluding VAT)
ONCE OFF DESIGN & PROGRAM FEE ( payable with first debit / EFT, Annual fee)
MONTHLY* / ANNUALY:
COMMENCEMENT DATE:
ACCOUNT TYPE:
BANK:
BRANCH CODE:
BANK ACCOUNT NAME:
ACCOUNT NO:
VAT NO:
This signed Authority and Mandate refers to our agreement as dated as on signature hereof. I / We hereby authorise you to issue and deliver payment instructions to the bank for collection against my / our abovementioned account at my / our above mentioned bank (or any other bank or branch to which I / We may transfer my / our account) on condition that the sum of such payment instructions will never exceed my / our obligations as agreed to in this document and commencing on the commencement date and continuing until this Authority and Mandate is terminated by me / us by giving you notice in writing of no less than 20 ordinary working days, and delivered to your address indicated above. The individual payment instructions so authorised to be issued must be issued and delivered as follows Monthly; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may
not be more or less that the obligation due; In the event that the payment day falls on a Saturday, Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and re-present the instruction for payment as soon as sufficient funds are available in my account;
Annually; on or after the dates when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not be more or less than the obligation due;
I / We understand that the withdrawals hereby authorised will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.
MANDATE: I / We acknowledge that all payment instructions issued by you shall be treated by my/our above mentioned bank as if the instructions had been issued by me/us personally.
CANCELLATION: I / We agree that although this Authority and Mandate may be cancelled by me / we, such cancellation will not cancel the Agreement. I / We shall not be entitled to any refund of amounts which you have withdrawn while this authority was in force, if such amounts were legally owing to you.
ASSIGNMENT: I / We acknowledge that this Authority and Mandate has been ceded to Netcash (Pty) Ltd as per your agreement with Netcash (Pty) Ltd, but in the absence of such assignment of the Agreement, this Authority and Mandate will be null and void.
FOR BUSINESS – Duly authorised
Signed at __________________________ on the ______day of ___________________________ 20____ _____________________ ____________________ ____________________
NAME & SIGNATURE WITNESS Page 7/7