I/We do hereby request the Ombudsman for Long-Term Insurance to investigate and consider the dispute with my/our insurance company. All relevant correspondence or documentation is attached.

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    Title

    First Name *[?]

    Last Name * [?]

    Postal Address * [?]

    Postal Code * [?]

    Telephone Number * [?]

    Cellphone Number * [?]

    Fax Number [?]

    E-mail Address [?]

    Policy Holder Full Name * [?]

    Policy Holder Date of birth / ID * [?]

    Policy Number [?]

    Type of Policy [?]

    Name of Insurance Company Involved * [?]

    Details of Complaint

    Would you kindly set out legibly all the facts which you consider have a bearing upon this complaint; including dates, places and names.

    Attach Documents (Maximum Upload 6MB) Extensions Allowed (pdf,word and scanned Docs)

    l will send manually





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