Complaints Form

eComplaint Form

COMPLAINANT INFORMATION

First Name

Last Name

Phone (home)

Phone (mobile)

Street Address

City

Region/State/Province

Postal / Zip code

Country

Relationship to the Policyholder/Insured

POLICYHOLDER INFORMATION

Type of Insurance Policy * Required

Auto

Home

Life

Medical

Other

Name of Insurance Company

COMPLAINT INFORMATION

1. Have you officially filed a complaint with your insurance company? * Required

Yes

2. Has the insurance company given you its final position in writing regarding your complaint? * Required

Yes

3. Has there been any court/tribunal/arbitration proceeding related to this complaint? * Required

Yes

(If YES, please provide details):

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

Full Name

Full NAME

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

Please provide copy of the final position letter.

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