Complaints Form

eComplaint Form

    Policy Holder Information

    First Name *

    Last Name *

    Date of Birth *

    Phone (home) *

    Phone (mobile) *

    Street Address *

    City *

    Region/State/Province *

    Postal / Zip code *

    Country *

    Insurance Company *

    Policy Number of Policy *

    Type of Policy *

    Complainant Information

    First Name *

    Last Name *

    Phone (home) *

    Phone (mobile) *

    Email Address *

    Street Address *

    City *

    Region/State/Province *

    Postal / Zip code *

    Country *

    Relationship with Policyholder *

    If Other (Please explain)

    Details Of Complaint

    Nature of Complaint *

    SUMMARY OF YOUR COMPLAINT (Please provide full details of complaint below):

    Provide the name of the person(s) you contacted at the insurance company.*

    Provide the email of the person(s) you contacted at the insurance company. (If Applicable) if not type N/A *

    Have you submitted a written complaint to your insurance company/agent/broker? *

    If Yes, please upload a copy.

    Upload supported file (Max 15MB)

    When did you first complain to the insurance company/agent/broker? *

    Has there been any other body involved in the proceedings related to this complaint? *

    If Yes, please select one.

    Please provide supportive email correspondence, company letters, police reports, medical reports.

    Upload supported file (Max 15MB)