Online Claim Application

Complete a claim form

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Name

First

Last

Layout

Tel

Cell

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Layout

Type Of Policy

Account Name

Business Name/Personal Name

Current Insurer

eg. Santam

Business Reg No/ ID No

Policy No.

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Type Of A Loss

Short-Term Insurance Products (Personal)

Type Of A Loss

Short-Term Insurance (Business)

Date

Incident Date/ Estimated Date Of Loss

Attach Current Policy Schedule(pdf)

Click or drag files to this area to upload. You can upload up to 2 files.

Current Claim No

if applicable

Attach Any Supporting Document(pdf)

Click or drag files to this area to upload. You can upload up to 5 files.

Short Description Of The Incident Or Loss..