Online Application Commercial or Personal? * Commercial Personal Where did you learn about the Office of the Ombudsman for Short-Term Insurance? * -- Select an option -- Newspaper Television Magazine Radio Internet Your Broker Your Insurer Your Attorney Other Ombudsman Your Bank Motor Dealer Your Policy Document Rejection Letter By word of mouth from a friend Not Provided Other Other: * 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: * -- Select an option -- Mr. Mrs. Ms. First Name: * Last Name: * Identification Type: * -- Select an option -- South African ID Number Passport Number Company Registration Number ID \ Passport Number: * Province of Residence: * -- Select an option -- Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga North West Northern Cape Western Cape Designation: * Date of Birth: * Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 First Language: -- Select an option -- Afrikaans English Ndebele Pedi Sesotho Swati Tswana Venda Xhosa Xitsonga Zulu English Literacy: * -- Select an option -- No Yes Race: -- Select an option -- Asian Black Coloured White Do you have any personal vulnerabilities we should be aware of? Postal Address P.O. Box: * Suburb: * Country: Afghanistan Albania Algeria Andorra Angola Anguilla Antigua & Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia & Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Myanmar/Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana Gabon Gambia Georgia Germany Ghana Great Britain Greece Grenada Guadeloupe Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Israel and the Occupied Territories Italy Ivory Coast (Cote d'Ivoire) Jamaica Japan Jordan Kazakhstan Kenya Kosovo Kuwait Kyrgyz Republic (Kyrgyzstan) Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Republic of Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Martinique Mauritania Mauritius Mayotte Mexico Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nepal Netherlands New Zealand Nicaragua Niger Nigeria Korea, Democratic Republic of (North Korea) Norway Oman Pacific Islands Pakistan Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent's & Grenadines Samoa Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovak Republic (Slovakia) Slovenia Solomon Islands Somalia South Africa Korea, Republic of (South Korea) South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor Leste Togo Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Uganda Ukraine United Arab Emirates United States of America (USA) Uruguay Uzbekistan Venezuela Vietnam Virgin Islands (UK) Virgin Islands (US) Yemen Zambia Zimbabwe 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: -- Select an option -- Abacus Insurance Limited Absa Insurance Co Ltd AIG insurance Allianz Insurance Co Ltd Aurora Insurance Company Limited Auto & General Insurance Co Ltd Bidvest Insurance Limited Bryte Insurance Co Ltd Budget Insurance Co Ltd Centriq Insurance Company (RF) Limited CFAO Motors Insurance Company Ltd Chubb Insurance South Africa Limited Clientele General Insurance Limited Compass Insurance Co Ltd Corporate Guarantee Dial Direct Insurance Co Ltd Discovery Insure Ltd Dotsure Ltd First for Woman Insurance FirstRand Insurance Ltd Genric Insurance Guardrisk Insurance Co Ltd Hollard Insurance Co Ltd Hollard Specialist Insurance Company Limited Indequity Specialised Insurance Ltd Infiniti Insurance Limited JDG Micro Insurance Ltd King Price Insurance Co Ltd Landbank Insurance Company (soc) Ltd Legal Expenses Insurance Southern Africa Limited LLoyds Lombard Insurance Group MiWay Insurance Limited Momentum Insure Company Ltd Monarch Insurance Co Ltd MUTUAL & FEDERAL RISK FINANCING Nedinsurance Co Ltd New National Assurance Co Ltd NMS Insurance Old Mutual Insure Ltd Outsurance Insurance Co Ltd PPS Insurance Relyant Insurance Co Ltd Renasa Insurance Company Limited S A Home Loans SAFIRE Insurance Co Ltd Santam Ltd Santam Structured Insurance Limited SASRIA Ltd Shoprite Insurance Company Standard Insurance Ltd Sunderland Marine Africa Swiss Re Corporate Solutions Africa Ltd Vodacom Insurance Company Ltd Western National Insurance Company Ltd Workers Life Insurance Limited Yard Insurance Limited Other Name of Insurance Company: Policy Number: Claim Number: Type of Policy: Home Owners Household Contents Motor Other Date Dispute Arose Date of Loss / Accident: Amount Claimed: R 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: Clear Letter from Insurer rejecting the claim: Clear Documentation relevant to the complaint including correspondence with Insurer: Clear Legible Copy of Identity Document or Passport: Clear Power of Attorney in favour of the person acting on behalf of the complainant, where applicable: Clear 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 Submit Application Please wait while your application is being saved. 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