JSJ Complaint Form

Client Information

Full Name

Address

Home Phone

Work Phone

Mobile Phone

Relationship to the Insured

Policy Information

Are you the policyholder?

Yes

If you have answered NO, please give policyholder details below.

Name

Address

Daytime Phone

Policy number or claim number or other reference

Complaint Information

Name of the insurance company/agent/broker/salesperson you are complaining about.

List the name of the person or persons whom you have contacted -- insurance company/agent/broker/salesperson

Full Name

Description Of The Product Or Service You Are Complaining About

Dropdown

When did the advice, transaction or poor service that you are complaining about take place?

When did you first notice that there might be a problem?

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

Has the insurance company/agent/broker/salesperson sent you its final decision on your complaint in writing?

Yes

Have there been any court/tribunal/arbitration proceedings relating to your complaint - or are any court/tribunal/arbitration proceedings planned?

Yes

Have you contacted any other financial services regulator about your compliant?

Yes

If you have answered YES to either of these questions, please give details here:

Complaint Details

Summary of your complaint

Recommendations

What resolution would you like?