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: *

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: *

Broker / Agent

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 Claim Rejected: *

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

Lodge Complaint Online