© Copyright 2016 All Rights Reserved   |  Price-Sure cc
518 Gariep Street, Erasmuskloof, Pretoria East, 0048 | 082 7790 242 | pricesure@mweb.co.za  | www.pricesure.co.za 
REG. NO: CC91/32692/23;  FSP LICENSE NO: 12565;  FIA NO: F003282
FREE TICKET, QUOTATION ORDER AND AUTHORIZATION LETTER N.B. Requirement before you can receive a ticket for any event arranged by us: (We must receive from you a hardcopy of latest schedule/policy summary and claim-history on letterhead of insured as well as this completed and signed authorization letter within 7 days before the event – please e-mail to us).  A once-off administration fee of R80.00 will apply on activation of the policy. FOR COMMERCIAL POLICIES: Company:    ______________________________________________ Registration No:   ______________________________________________ How many branches:  ______________ Current Commercial Short-term Policy numbers     1. _______________  2. _________________ Insurer: __________________   Broker-house: ______________________ FOR PERSONAL POLICIES: Surname & Initials:   _____________________________________________ ID Number:    _____________________________________________ Current Personal Short-term Policy numbers: 1. _______________ 2. _______________ Insurer: __________________   Broker-house: ______________________ I    hereby    authorize    Price-sure    CC,    any    insurer,    and    any    underwriter/administrator    appointed    by    Price-sure,   to   access my   credit   information   and   my   Insurance   Credit   score(ICS)   held   by   one   or   more    of   the   registered   credit   bureau   as   well   as to   verify   and   share   policy   and   insurance   information   with    insurers     and     other     institutions.             I     also     authorize     Price- sure     CC     to     withdraw     all     necessary   information at any insurance company to supply me with a quotation. My contact details are: 1 . Landline: ____________________ 2.Cellular phone: ____________________________ 2 . Email address:  ____________________________ 3. Year of Driver’s license initially issued  __________ Driver’s license Code  _________ 4. Number of years insured in total   __________ 5. Did the client have any claims in the past 3 years on any of the items being quoted on? _________ Signed at   ----------------------------------------     on this  ------- day of---------------------------      20--------- Client:    _________________________
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