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THE OMBUDSMAN

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THE OMBUDSMAN Powered By Docstoc
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   APPLICATION FOR ASSISTANCE
                         (COMMERCIAL COMPLAINTS)
   1.   I ______________________________________________________________________ say that:

                This complaint is not in the hands of an attorney for any purpose other than the drafting of this
                 complaint and is not subject to litigation or arbitration.

                The Insurer and/or Broker has, as far as we can ascertain, finally declined the complaint.

                The complaint is in respect of our commercial business insurance as set out in this application and
                 does not involve anyone else’s Insurer.

                We have tried unsuccessfully to resolve the dispute through approaches to the Insurer or
                 Intermediary’s Management or its internal complaints handling section

   2.   It is understood and agreed that by submission of this form:

                the matter will be regarded as confidential as between ourselves, the Insurer and/or the Broker
                 and the Ombudsman and it is for the Ombudsman to decide what should be disclosed to us
                 and/or the Insurer;

                documents brought into being as a result of our approach to the Ombudsman shall not be liable
                 to disclosure or be the subject of a discovery order or subpoena in the event of proceeding,
                 between ourselves and the Insurer and/or the Broker;

                the Ombudsman will not be liable to be subpoenaed to give evidence on the subject of the
                 complaint in any proceedings;

                the services rendered by the Ombudsman are not the same as those rendered by a professional
                 legal adviser and are confined purely to determination, mediation or conciliation in an attempt to
                 settle complaints against a member of the Ombudsman’s office (Incorporated under Section 21).
                 Neither the Ombudsman nor any of his staff shall be liable for any loss or damages sustained by
                 the complainant arising out of their activities, whether such claim is based upon negligence,
                 breach of contract or any other cause of action.

                The annual turnover of our business does not exceed R10 million and the dispute amount does
                 not exceed R1 000 000 in total.

   3.   No one is entitled to obtain payment for supplying this document to us

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   Authorised Signatory                                                      Date
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                   COMMERCIAL INSURANCE COMPLAINTS HANDLED BY
                OMBUDSMAN FOR SHORT-TERM INSURANCE ARE LIMITED TO:


     1.    Complainants
           Small businesses, including a sole proprietor or trader, a juristic person, partnership or trust and that
           had a turnover in the last financial year of less than R10 million.
     2.    Claims and other disputes restricted to the following types of cover
           Fire and Allied Perils - (if there is an involvement of loss of profits /
                                                business interruption, the entire complaint falls outside this office’s
                                                mandate)
           Glass
           Theft
           Motor
           Travel
           Sickness and Accident
           SASRIA Claims (affiliated to the aforesaid covers)
     3.    Disputes involving amounts not exceeding R1 000 000 in total.




      WHERE DID YOU LEARN ABOUT THE OFFICE OF THE OMBUDSMAN FOR SHORT-TERM
                                   INSURANCE


          Newspaper
          Television
          Magazine
          Radio
          Your Broker
          Your Insurer
          Your Attorney
          Other Ombudsman
          Your Bank
          Motor Dealer
          Your Policy Document
          The letter of declinature
          By word of mouth from a friend
          Other (please specify) _______________________________________




    COPIES OF DOCUMENTS WHICH YOU COULD ATTACH TO HELP SPEED UP THE RESOLUTION
                                    PROCESS


            Letter of declinature
            Policy Schedule / Certificate of Insurance
            Any correspondence, with the Insurer relevant to the complaint
                                                                                                             Page 3/6




                                              APPLICATION
To be completed and returned to the Ombudsman for Short-Term Insurance.

P O Box 32334                              Telephone             : (011) 726-8900
BRAAMFONTEIN                               Fax                   : (011) 726-5501
2017                                               E-mail        :         info@osti.co.za

I/We apply for the Ombudsman to investigate and consider the dispute with my/our insurance company. All relevant
correspondence is attached.

                                          PARTICULARS OF COMPLAINT

 Details of Policy Holder(*) ___________________________________________________________
 Authorised Person lodging complaint on behalf of Policy Holder(*):
 __________________________________________________________________________________
 Authorised Person’s ID. No. (*): ______________________________________________________
 Designation(*): ___________________________________ Mr/Mrs/Miss: ____________________
 Surname(*): _________________________ Initials(*): __________________________________
 Company/ cc. Registration Number/ ID. No.(*): _________________________________________
 Postal Address(*): __________________________________________________________________
 ________________________________________________________ Postal Code: ______________
 Telephone: (Business) __________________________ (Cell) _______________________________
                 (Alternate Contact No.) _______________________ (Fax) _____________________
                 (E-mail address) _________________________________________________________

 Estimated Annual Turnover (*): ______________________________________________________
 We would prefer corresponding with you via e-mail, as this will facilitate speedy and expeditious communication between our offices
 and yourself.
 If you have not received correspondence from our office within 10-working days acknowledging receipt of your complaint, kindly
 contact our offices to confirm that your complaint has in fact been received by our office and to obtain the file reference number
 allocated to your complaint.


 Policy number(*): _________________________________________________________________
 Claim number(*): _________________________________________________________________
 Type of policy: ___________________________________________________________________

 Insurance Company(*): _____________________________________________________________
 Date claim declined: ____________________ Date of loss / Accident: _____________________

 Amount claimed: __________________________________________________________________
 If your matter has been referred to another Ombudsman’s office kindly furnish us with details of the other Ombudsman and their
 reference number, alternatively if you have / had a complaint with our offices, kindly furnish us with such ref. no.
 __________________________________________________________________________________
 If you are not sure of who your insurer is, please furnish us with a copy of your policy schedule and/or declinature letter.
 Name of Broker / Agent: ____________________________________________________________

 Postal Address: ____________________________________________________________________

 Telephone: ________________________________ Fax: __________________________________

 Please note that fields marked with an * are compulsory fields. If this info is not provided, your complaint will be not be able to be
 pursued.
                                                                                                 Page 4/6


                          DETAILS OF COMPLAINT

Here set out legibly all the facts which you consider have bearing upon this complaint, including dates,
places and names. Attach copies of all relevant documents. (If the space is not sufficient use own
additional pages).
The details should sufficiently set out the nature of the claim, the reasons for the declinature of the claim
and the basis of your dissatisfaction with the insurer’s decision.

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DETAILS OF COMPLAINT CONTINUED…….                                        Page 5/6

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         WHAT I WANT FROM THE OMBUDSMAN

(Here set out shortly but exactly what relief you are asking for)


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