Submit a complaint

Policy number / Polisnommer: *

Name & Surname / Naam & Van: (required)

Residential address / Woonadres: *

Postal address / Posadres: *

Email / E-posadres: *

Contact numbers / Kontaknommers: *
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Nature of complaint / Aard van klagte: *

Claim / EisPremiums / PremiesService of Legalex / Diens van LegalexService of 3rd Party / Diens van 3de PartyThe Policy / Die PolisOther / Ander

Particulars of complaint / Besonderhede van klagte: *

Member signature / Lid handtekening : *