Insurance Agent Form

Let’s get you covered!

To get you covered, their agent will contact you to setup your policy and nominate your beneficaries.

Full Names

Surname

Email Address

Cell Number

ID Number

I agree to allow HYPA to share my details with iNFUSSION Brokers to contact me about my benefit options

Yes

I would like to add free Commuter Insurance to my HYPA package

Yes

I would like to hear more about

Funeral cover for R20 per month

Other benefit packages from iNFUSSION Brokers

All of the above

Date of Birth (Do not opt in if you are younger than 18 or over 64)

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*The HYPA Commuter Plan is marketed and sold by iNFUSSION BROKERS (Pty) Ltd, an authorized Financial Services Provider, FSP No. 48548. Administered by Infussion Financial Services (Pty) Ltd, an authorised Financial Service Provider, FSP No. 35953. Underwritten by Lion of Africa Assurance Company Limited, a licensed life assurance company and an authorised Financial Services Provider, FSP No. 15283.