I confirm that the information I have provided is my personal data and, where it is not my personal data, that I have the consent of the owner of such personal data to provide such information.

By providing this information, I understand and give my consent for OUR FIRM AND OUR PARTNERS to:

a. Collect, use, store, transfer and/ or disclose the information, to or with all such persons to provide me with services required of an insurance provider, including the evaluating, processing, administering and/ or managing of my relationship and policy(ies) with OUR FIRM AND OUR PARTNERS.

b. Collect, use, store, transfer and/ or disclose personal data about me and those whose personal data I have provided from sources other than myself for the Purposes.

c. Contact me to share with me information about products and services from OUR FIRM AND OUR PARTNERS that may be of interest to me by post and e-mail and

1) By telephone,
2) By fax and
3) By text message* Required

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