Complaint Form Customer Complaint Form If you are human, leave this field blank. Date of complaint * Complaint Type * Claim Debit Order Premium Policy Documents Application Benefits Other Complaint Type Policy Number or your ID Number * Title * Full Name & Surname * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Phone * Email * Brokerage Product * Kaelo Gap Sanlam Gap Kaelo Health Western Gap MedExpense Flexicare Responsible Person's Name (Kaelo representative whom I have been dealing with) * What happened to cause you to be dissatisfied? * How can we make this right? * reCAPTCHA Submit Please wait...
