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Complaints Form

Please provide us with as much information as possible to assist us in helping resolve your complaint.
Items marked with * are required.
Title*
Please select a title

First Name*
Please enter your first name

Last Name*
Please enter your surname

Address (Postal)*
Please enter your postal address

Suburb*
Please enter your suburb

State*
Please select your state

Postcode*
Please enter your postcode

Phone Number*
Please enter a valid phone number, comprised of 10 digits, including area code e.g. 02

Email Address

How should we contact you?*
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Insurance Policy Type

Policy Number
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Complaint Details

Complaint relates to*
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Description of Complaint*
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Please attach copies of any documents, photos or information that might help us review your complaint.
The following formats are supported: .txt .rtf .doc .docx .xls .xlsx .pages .numbers .jpg .jpeg .png .gif .pdf
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