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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