Complaint Form

Please complete all information below

a. Information of policy holder (complainant):
Title
Identity Number
Surname
First Names
Physical Address line 1
Physical Address Line 2
Suburb
City
Province
Code
Home Telephone Number
Cellphone Number
Work Telephone Number
Email Address
example@example.com
Policy Number
Claim Number
Type of Policy
Date of Claim Rejected If applicable

Year Month Day
Date
Date of Accident Loss

Year Month Day
Date
Details of Complaint

c. Please legibly set out all the facts which you consider to have bearing on this complaint including dates places and names Attach copies of all relevant documents If the space is not sufficient you may add additional pages The details should set out a the facts which gave rise to the claim b the reasons for the rejection of the claim and c why you are dissatisfied with the insurers decision
d. Complaint Resolution How do you suggest we resolve your complaint
Please upload any supporting documents needed for your complaint

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