| Please complete the following registration form for the Eezi Assist Button |
Policyholders Details
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| Title |
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| First Name |
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| Surname |
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| ID Number |
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| Policy Number |
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| Mobile Number |
eg 27821234000 |
| Email |
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Security Company (optional)
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| Name of Security Co |
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| Telephone Number |
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| Home Address |
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Medical Aids Details (Optional)
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| Name of Medical Aid |
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| Medical Aid Number |
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Additional 1
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| Title |
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| First Name |
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| Surname |
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| Relation to Member |
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| Mobile Number |
eg 27821234000 |
| ID Number |
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Additional 2
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| Title |
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| First Name |
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| Surname |
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| Relation to Member |
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| Mobile Number |
eg 27821234000 |
| ID Number |
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Additional 3
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| Title |
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| First Name |
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| Surname |
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| Relation to Member |
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| Mobile Number |
eg 27821234000 |
| ID Number |
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| By ticking the “I Agree” box you consent to being located by Eezi Assist using an assist system from cellfind for personal safety. |
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I Agree |
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Read Terms and Conditions |
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