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If you would like us to do a financial health report for you, please contact us or SMS OR WHATSAPP “YES” to 0743596018 or send an email to

    1) Financial Juristic Representatives:
    Name and Surname: Etienne de Villiers / Leo de Villiers
    Telephone Number: Etienne Cell: 082 880 1436 / Leo de Villiers Cell: 074 359 6018
    E-mail address:;
    Financial services provider details: Shield Life FSP 47477

    2) Client:

    Confidentiality: I acknowledge that the financial planner operates in an office environment of Shield Life, and I agree that an office assistant may from time-to-time attend to general policy enquiries. The financial planner agrees that such information is always treated in strict confidentiality and under control of the financial planner. Shield Life may request information on my behalf, and I consent to the use of the information for the purposes stated in this document. Shield Life has undertaken to treat all my information as confidential and may not be made public in any way without my written consent.

    Authority to disclose information: I agree that Shield Life may make available existing information to the planner for using in the process of providing me with financial services. I also consent that Shield Life may disclose and process my personal information as part of their normal business processes.

    Credit Report authority: To this end and to best serve my interests, I consent to the release of my Credit Report Information to Transafrica Life (represented by the financial Juristic Representative named above, or a financial representative whom Transafrica Life might charge with such duty, or an office assistant operating in an office environment of such financial representative), through a registered financial institution, an authorised Financial Services Provider, or an institution providing a similar service.

    Communication: Shield Life or Afrisure may communicate notices and direct correspondence arising from this business relationship to me. Communication sent to me will be deemed to have been received within 24 hours after the time of transmission. I will notify Afrisure by sms, email or in writing, of changes in my contact details and such change will take effect upon confirmation from Afrisure.

    4) Client declaration
    I have read through the document and the content has been explained to me. I confirm that I understand the content and give my consent to obtain my information as stated above. I confirm that the document has been completed in full before it was signed. This consent shall remain effective until I cancel it in writing.

    If you want to find out more about these services, contact : Leo de Villiers Cell:  074 359 6018 Email: / Lorraine Afrisure Office 013 753 2040 Email: / Etienne Cell:  082 880 1436 Email:  / Email:

    Financial products questionnaire

      Please complete this to the best of your knowledge, the more correct information we have the better we will be able to help you……

      Name & Surname

      Email Address

      Contact Number

      Please List all the Institutions, The monthly Repayments & Total amount of the Loan

      1: Please list the personal loans you have and with what institutions?

      2: Cash loans / payday loans or unregistered loans?

      3: Funeral parlour

      3.1 Funeral policy

      3.2 Burial society

      4: Life Insurance Cover

      5: Short term insurance

      6: Home loans, Bonds

      6.1 Vehicle instalment

      7: Are you or have you been placed under debt review, sequestration or administration?


      Please update the following documents: