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									                                    (Incorporated under Section 21) (Registration Number 2000/030638/08)

                                   APPLICATION FOR ASSISTANCE (Commercial Lines Application)
To be completed and returned to the Ombudsman for Short-Term Insurance.
P O Box 32334                         Telephone:       (011) 726-8900        Sunnyside Office Park, 5th floor Building D
BRAAMFONTEIN                          Fax       :      (011) 726-5501        32 Princess of Wales Terrace
2017                                  E-mail :       Parktown
We apply to the Ombudsman to investigate and consider our complaint/dispute with our insurance company. All relevant
documentation is attached.
    1. I                                                ,Identity number:                        , duly authorised, declare that:
        (Please note that a legible copy of your passport or identity document must be attached.)
             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 our 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 our complaint/dispute through approaches to the Insurer or Intermediary’s
               Management or its internal complaints handling section and request the assistance of the Ombudsman in the
               resolution of the matter.

    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;

              We acknowledge that any finding of the Ombudsman shall not be binding upon us and that our legal rights against
               the Insurer are not affected thereby;

                 the Ombudsman will 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

              the services rendered by the Ombudsman are not the same as those rendered by a professional legal adviser and
               are confined purely to recommendation, 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 in dispute does not exceed
               R1 million in total.

              We undertake to be bound by the Ombudsman’s Terms of Reference.

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

    Signature of complainant or person authorised to act on his/her behalf                                 Date

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 are generally restricted to the following types of cover
   Fire and Allied Perils
   Sickness and Accident
   SASRIA Claims (affiliated to the aforesaid covers)
   Unless the insurer concerned should consent to the jurisdiction of the Ombudsman to consider any complaint.

3. Disputes involving amounts not exceeding R1 million in total.

                                     COPIES OF DOCUMENTS WHICH MUST BE ATTACHED

              Legible Copy of Identity Document or Passport of the person mandated to complete this form
              Letter of declinature / Rejection Letter
              Policy Schedule / Certificate of Insurance
              Any correspondence with the Insurer relevant to the complaint
              Certificate of Annual Turnover from Auditors(if required)

Please note:

Kindly complete the form in a legible manner. Please note that the fields marked with an * are compulsory.

Our preferred mode of correspondence is via e-mail, as this will facilitate speedy and expeditious communication between
our offices and yourself.

Where the contact person is not the complainant, then please provide us with the relevant person’s correct contact details. If
the contact person is acting on your behalf, then a Power of Attorney must also be provided.

If your matter has been previously referred to another Ombudsman’s office or other dispute resolution forum, kindly furnish
us with details of the other Ombudsman and /or forum and their reference number, alternatively if you have / had a complaint
with our offices, kindly furnish us with such reference number ...................................

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 been received by our office and to obtain the file reference
number allocated to your complaint.

If you are unsure of the name of your Insurer, please furnish us with a copy of your policy schedule and/or rejection letter.

                                                                   PARTICULARS OF COMPLAINT

Name of Policy Holder(*)_______________________________________________________________________________________
Authorised Person lodging complaint on behalf of Policy Holder(*) ______________________________________________________
Authorised Person’s ID. No. (*) ____________________________________ Designation(*) _________________________________
Mr/Mrs/Miss/Ms ________ Surname _________________________________ Initials(*) ____________________________________
Company/CC Registration Number/ ID. No.(*) ______________________________________________________________________
Postal Address(*) _____________________________________________________________________________________________
_____________________________________________________________________ Postal Code ___________________________
Physical Address(*) --------------------------------------------------------------------------------------------------------------------------------------------------------
Business Telephone ___________________________________ Alternate Contact No______________________________________
Email Address _________________________________________________ Fax __________________________________________
Estimated Annual Turnover(*) ___________________________________________________________________________________

Name of Broker / Agent: _______________________________________________________________________________________
Postal Address ______________________________________________________________________________________________
Telephone ____________________                             Fax ______________________                      Email Address ______________________________

Name of Insurance Company(*) _________________________________________________________________________________
Policy number(*) _____________________________________________________________________________________________
Claim number(*) _____________________________________________________________________________________________
Type of policy _______________________________________________________________________________________________
Date claim rejected _______________________________                                            Date of loss / Accident: ______________________________
Amount claimed _____________________________________________________________________________________________

The following section is only to be completed if the complaint deals with a motor policy.
1. Is your vehicle financed?                                                                                                                     Yes                   No
2. Do you enjoy Credit Shortfall/Deposit Protection/Top-up Cover/ Ad Cover or Violation Cover?                                                   Yes                   No
3. If yes, please provide us with the following information:

Name of Financier and Insurance Company(*)______________________________________________________________________
Policy number(*) _____________________________________________________________________________________________
Claim number(*) _____________________________________________________________________________________________
Type        of      policy___________________________________________________________________________________________

                                                          DETAILS OF COMPLAINT

Please legibly set out all the facts which you consider to have bearing upon 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 the nature of the claim, the
reasons for the declinature of the claim and the basis of your dissatisfaction with the insurer’s decision.


Please briefly set out the relief you are seeking:


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