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Ombudsman Complaint Form1

This document is a complaint filed against an insurance company. [1] It provides details of the complainant such as their name, address, and contact information. [2] It also lists the name and address of the insurance company being complained about. [3] The complaint references a specific insurance policy number and states that the complainant is aggrieved but does not provide details of the subject matter of the complaint.

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Utsav J Bhatt
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228 views2 pages

Ombudsman Complaint Form1

This document is a complaint filed against an insurance company. [1] It provides details of the complainant such as their name, address, and contact information. [2] It also lists the name and address of the insurance company being complained about. [3] The complaint references a specific insurance policy number and states that the complainant is aggrieved but does not provide details of the subject matter of the complaint.

Uploaded by

Utsav J Bhatt
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ANNEX-VI A Complaint No. (td. Complaint No.

To,
The Insurance Ombudsman
(td Centre address)

Re: Complaint against: (td Insurance Company)


Branch/ Devision: (td Branch)
Policy No. (td Policy no.)

Name of Complainant

...............................................

Being aggrieved, I am lodging complaint against the above referred insurance Company.

Details are given as under:

1. Complainant’s Full Name and Address

Name of the complainant: (name of Complainant)


Address: (Full address)

Telephone No.: (Telephone No.)


Landline No.: (Landline No.)
Mobile No.: (Mobile No.)
Relationship to the
Insured Person: (td Relationship)

2. Name of the Insurance


Company: (td Insurance)

Office address: (Insurance office address)


Branch: (td Branch)

3. Policy No.: (td policy No.)

4. Subject Matter of complaint


and brief fact of the case : -------------------------------------------------------------------------

5. Date of preferring your claim/


Complaint to the office
(Please enclose copy of the letter)--------------------------------------------------------------------------
6. Date of reply of Insurance Company -----------------------------------------------------------------------------
(Please enclose a copy of letter)

7. Any proceeding before any court/-------------------------------------------------------------------------------


Consumer Forum/ Arbitrator on --------------------------------------------------------------------------------
the Same subject matter pending--------------------------------------------------------------------------------
or were So earlier

8. Nature or extent of monetary -----------------------------------------------------------------------------------


Loss, if any ( In case of General -----------------------------------------------------------------------------------
Insurance only) --------------------------------------------------------------------------------------

9. Quantum of relief sought ----------------------------------------------------------------------------------------

10. (a) Particulars of representation ----------------------------------------------------------------------------------


made against repudiation of ---------------------------------------------------------------------------------------
claim to DO/RO/ZO/grievance-------------------------------------------------------------------------------------
cell and outcome thereof ----------------------------------------------------------------------------------------

(b) If not made representation-------------------------------------------------------------------------------------


not made give reason, if any --------------------------------------------------------------------------------------

11. I hereby declare and solemnly affirm that


(a) The information given above is true to the best of my knowledge and belief

(b) The complaint was lodged with the Insurance Company on (dt complaint date) as per copy
enclosed and the company has rejected my claim/complaint/not replied even after a month
/replied on (dt repudiation Date) but the same is not accepted to me.

(c) The period of one year has not elapsed from the date of rejection letter or final from the
insurance company

(d) The complaint is not on the same subject matter for which any proceedings before any court
or consumer forum or a arbitrator are pending /settled or were so earlier.

(e) The subject matter is not decided earlier by your office or any office of the Insurance
Ombudsman

12. I/we enclose copies of the following documents:


1. Copy of complaint letter written to the Insurance Company
2. Copy of reply received from the said insurance Company
3. Copy of reminder if any

Yours faithfully
(Signature of the complainant)

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