Skip to main content
Tools
Support
FAQ
LOGIN
Member Login
Service Provider Login
Agent/Broker Login
Home
About Us
Overview
Board of Trustees
Management
Our Clients
Awards
Our Partners
Our Plans
All Our Plans
Fund Rules
Waiting Periods
Broker Zones
Agent Registration And Ammendment Form
Agent/Broker Login
Broker Application Form
Service Provider
Service Provider Login
Member Zone
Generation Health Banking Details
Member Login
Member Record Amendment Form
Membership Card Request Form
Organisation Application Ammendment Form
UNIPLAN Application or Renewal Form
Forms
Broker Zones
Member Zones
Service Provider Zones
Media
Blog
News & Inights
Health Tips
FAQs
Video Gallery
Contact Us
Broker Zones
|
Agent Registration And Ammendment Form
Agent Registration And Ammendment Form
You are here
Home
»
Broker Zones
Agent Registration And Ammendment Form
1
Start
2
Complete
Section A: Type of Transaction: Please select appropriately below
Type of Transaction:
*
- Select -
New registration
Amendment of details
Section B: Organisation details: This section must be completed by the agent
Title :
*
- Select -
Mr
Mrs
Ms
Miss
Dr
Prof
Sir
Fr
Sr
Eng
Sgt
Bishop
Honourable
Rev
Pastor
Surname :
*
Maiden Name :
First Name/s :
*
ID Number :
*
This is required for Zimbabwean citizens
Passport Number :
This is a requirement for Foreign Nationals
Date of Birth :
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Gender :
*
- Select -
Male
Female
Marital Status :
*
- Select -
Single
Married
Divorced
Widowed
Race :
*
- Select -
Black
Coloured
Indian
Asian
White
Cellphone :
*
Telephone (W) :
Telephone (H) :
Physical Address :
*
Postal Address :
Email :
*
Start Date :
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2020
2021
2022
2023
2024
Section C: Banking details for commission payments
:
Proof of banking details required in the form of letter from the bank or banking details on company letterhead signed and stamped by the relevant issuer
Bank Name :
*
Branch Code :
*
Branch Name
*
Account Number :
*
Account Holder :
*
Account Type :
*
- Select -
Cheque
Saving