JSJ Complaint Form

Summary of complaint

Insurance product or service relevant to your complaint

Policy number, claim number or other reference

Name of policyholder

Policyholder address

Policyholder daytime phone

Policyholder other phone

Policyholder email

Complaintant full name

If different from policy holder, what relation is complaintant to policyholder?

Complaintant address

Complaintant daytime phone

Complaintant email

Complaintant other phone

Details of complaint

Full name(s) of insurance company/agent/broker/salesperson relevant to your complaint

When did the subject of your complaint occur?

When did you first notice there might be a problem?

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

Full name(s) of individuals and/or companies you have contacted regarding your complaint

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

Yes

Have any court/tribunal/arbitration proceedings related to your complaint been conducted or planned?

Yes

Have you contacted any financial service regulator about your complaint?

Yes

Please provide any additional details that might be helpful

What resolution do you propose?