The Ombudsman for Short Term Insurance

Commercial or Personal? *

Where did you learn about the Office of the Ombudsman for Short-Term Insurance? *

Authorised Person lodging complaint on behalf of Policy Holder

Authorised Person's Name: *

Authorised Person's ID Number: *

Particulars of Complaint

Policy Holder Full name(s):

Salutation: *

First Name: *

Last Name: *

Identification Type: *

ID \ Passport Number: *

Province of Residence: *

Designation: *

Date of Birth: *

First Language:

English Literacy: *

Race:

Do you have any personal vulnerabilities we should be aware of?

Postal Address

P.O. Box:

Suburb:

Country:

Postal Code:

Physical Address

Street: *

Suburb:

Postal Code: *

Contact Details

Home Phone Number:

Cell Phone Number: *

Business Phone Number: *

Fax Number:

Alternate Contact Number:

Email Address: *

Confirm Email Address: *

Name of Broker / Agent acting on your behalf (If applicable)

Name of Broker / Agent:

Broker / Agent Postal Address

P.O. Box:

Suburb:

Country:

Postal Code:

Broker / Agent Contact Details

Phone Number:

Fax Number:

Email Address:

Insurer Details

Name of Insurance Company:

Policy Number:

Claim Number:

Type of Policy:

Date Dispute Arose

Date of Loss / Accident:

Amount Claimed:

If the Complaint deals with a motor policy the following must be completed

Is your vehicle financed?

Do you enjoy Credit Shortfall / Deposit Protection / Top-up Cover / Ad Cover or Violation Cover?

If yes to any of the above, provide the following information:

Name of Financier and / or Insurance Company:

Policy Number:

Claim Number:

Type of Policy:

Complaint

Details of Complaint: *

What I want from the Ombudsman: *

Attachments

Policy Schedule / Certificate of Insurance:

Letter from Insurer rejecting the claim:

Documentation relevant to the complaint including correspondence with Insurer:

Legible Copy of Identity Document or Passport:

Power of Attorney in favour of the person acting on behalf of the complainant, where applicable:

I agree to the terms and conditions

You will receive an Email with a reference number once this form is submitted to confirm that the application went through successfully

Online Application

Authorised Person lodging complaint on behalf of Policy Holder

Particulars of Complaint

Postal Address

Physical Address

Contact Details

Name of Broker / Agent acting on your behalf (If applicable)

Broker / Agent Postal Address

Broker / Agent Contact Details

Insurer Details

If the Complaint deals with a motor policy the following must be completed

Complaint

Attachments

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