Efficient Broker Quote Request Form

This form is for Efficient brokers. For the non-Efficient brokers, please use this form: Broker quote request form

Section 1: Broker Information

Broker Name

Verso Broker Code

Company Name

Contact Number

Email Address

FIAS registration no

Billing Address
81 Dely Road, Hazelwood, Pretoria, 0081

Contact Person for Payment

Name

Phone Number

Email Address

Section 2: Client / Employer Information

Employer Registered Name

Employer Contact Person

Employer Contact Number

Employer Email Address

Employer Address

Type of Business

Affiliated Sector (Please specify)

Section 3: Cover Details

Type of Cover Required (select all that apply) Provident Fund (Savings)Death BenefitCapital Disability BenefitIncome Disability InsuranceAccidental Death BenefitFuneral Benefit

Number of Employee

Number of Salaried Employees

Number of Wage Earners

Estimated Annual Payroll

Desired Participation Date

Please note: One calendar month notice is required to install a new participating employer.

Section 4: Eligibility Criteria

I confirm all employees are between the ages of 16 and 65.

I confirm all employees are permanently employed.

Are there different categories of members?

YesNo

Section 5: Risk Benefit Selection

I elect risk benefits linked to the Fixed Plans.I elect risk benefits linked to the Tailor-made Solutions.I elect risk benefits not linked to the Fund Plans/ Solutions.

Section 6: Product Selection (Please refer to the Tariffs and Benefit Options)

Benefit / Setting	Category 1	Category 2	Category 3	Category 4	Category 5
Fixed Plan Selection

Section 6.1: Tailor-Made Solution (Please refer to the Tailor-Made Tariffs and Benefit Options): Benefit options detailed

Wage staff option

Benefit / Setting	Category 1	Category 2	Category 3	Category 4	Category 5
Contribution (Rand/member/month or % of Salary/Wage)
Lump Sum Death Benefit Multiple
Lump Sum Disability Benefit Multiple
Accidental Death Benefit Multiple
Income Disability Insurance
Tailored Funeral Benefits

Salary Staff Options

Benefit / Setting	Category 1	Category 2	Category 3	Category 4	Category 5
Contribution (Rand/member/month or % of Salary/Wage)
Lump Sum Death Benefit Multiple
Lump Sum Disability Benefit Multiple
Accidental Death Benefit Multiple
Income Disability Insurance
Tailored Funeral Benefits

Section 7: Selection (Independently Selected Risk Benefits)

Official risk benefit quote must be obtained from Sanlam and submitted with this form (incl. membership data).

Contributions per Category

Benefit / Setting	Category 1	Category 2	Category 3	Category 4	Category 5
Contribution (Rand/member/month or % of Salary/Wage)

Section 8: Additional Information

Any existing cover? YesNo

Cover type details

Current Provider(s)

Section 9: Terms & Conditions

All information provided must be accurate and complete.
The quote is based on supplied information and may change upon review.
All parties agree to comply with Fund rules and regulations.
Submission of this form does not guarantee coverage.

Section 10: Submission Deadline

This form must be submitted by
—

This date is determined by the desired Participation date selected. (section 3)

Section 11: Process After Submission

Upon submission, the form will be reviewed and the broker will be contacted within 24 hours for any additional information or clarification needed.
A quote will be provided to the broker within 24 hours after all necessary information has been reviewed.
If the quote is accepted, the broker and client will proceed with the necessary steps to finalise participation.

Section 12: Required Documents Checklist (Upload)

Please upload the following (PDF/JPG/PNG/ZIP; max 5MB each):

Directors’ IDs

Employer Proof of Address
must be less than three months old

Business Registration Documents

Employee List
Download Employee list template

Section 13: Declaration

Broker full name

Date

I hereby declare that the information provided is accurate and complete to the best of my knowledge, and I understand it will be used to provide a quote for the Agricultural and Affiliated Sectors Provident Fund.

Section 14: Contact Information for Enquirers

Phone: 087 330 2001
Email: agrisectorfund@verso.co.za

Notes & Submission

Additional Notes

comments or other information that may be pertinent to the quote.