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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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You can submit your complaint in any of the official languages

Would you kindly set out clearly all the facts which you consider have a bearing upon this complaint; including dates, places and names.
Attach Documents (Maximum Upload 10MB) Extensions Allowed (PDF, Word and scanned documents)

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