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Personal Lines Quotation Form

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Reference Number: zphni

Consent to POPIA
CONSENT TO PROCESS PERSONAL INFORMATION IN TERMS OF THE PROTECTION OF PERSONAL
INFORMATION ACT, NO. 4 OF 2013 (POPIA)

The Protection of Personal Information Act 4 of 2013 (“POPIA”) is South Africa’s Data protection law. It was created to give effect to the Constitutional right to privacy and protect the use of private information.

We will be collecting your personal information to enable us to fulfil the mandate that we have been given by you.
I, Ariana Jacpasad, a natural person (Data Subject) with ID no.: 0205130174555.

hereby give my consent to ProVérte Risk Management (Pty) Ltd (The Responsible Party) to collect, process and where legally required, distribute my personal information in accordance with the provisions of POPIA.

  1. I understand my right to privacy and the right to have my personal information processed in accordance with the conditions for the lawful processing of personal information.
  2. I understand the purposes for which my personal information is required and what it will be used for.
  3. I consent to third parties accessing the relevant information where necessary to perform their functions in relation to the services provided by ProVérte.
  4. I understand that ProVérte shares relevant and valuable information in the form of newsletters and updates to their clients, and consent is provided to add my email to their distribution database once we become a client.
  5. I understand my rights to request correction of personal information or object to the processing thereof in accordance with POPIA.
  6. I understand that should I refuse to provide the required consent and/or information ProVérte will not be able to do their job properly, the insurer’s may not be able to provide cover and I may not receive important and valuable information they share through newsletters.

This consent will remain effective until such consent is withdrawn.



Signed at 123 Internet this 17 day of May 2025.
Ariana



Signed at_______________________________________________________________________________________

this ___________ day of _____________ 20_______________.


Name + Surname of Responsible Party (Employee of ProVérte): _______________________________________________________________________________________






Signature: _____________________________________
I have read and consent to the POPIA Compliance Policy and I have signed the consent form. Yes
To enable the insurers to underwrite risk fairly and to combat insurance fraud, we need to have your consent to verify and share policy information with insurers and other institutions as well as to access credit information held by other institutions. Do you give consent? Yes
Personal Information
Full name & Surname: [155]
ID no. 0306140574523
Passport no.
Nationality:

DOB:
Marital Status
Occupation unemployed
Telephone Number: 0843424083
Email Address arianajacpasad@gmail.com
Address Information
Postal Address


, ,
Insurance History
Are you currently insured or did you have any previous Insurance – Yes or No
Details of previous insurance Comapany: Ariana Company

Policy Number:
Has any insurer / underwriter ever cancelled/declined/refused to renew/impose special terms or conditions or any policy held by you Yes

If yes –

Any losses in the last 5 years: Yes
Buildings/Contents Cover
Contents – Security Measures
Security Perimeter
Security Area
Security at the property (House)
Personal All Risk Cover
Unspecified All Risk Insured Amount
Personal Accident Cover
Watercraft Cover
permission to the insurers to share policy information and to perform a credit check with various credit bureaus to enable them to do proper underwriting and prepare a quotation. Yes
Signature
Date of Signing September 17, 2025
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