If you'd like to submit a complaint on-line, please provide the following information.
First Name *
Last Name *
Address *
Province *
Postal code *
Day Phone * Evening Phone
Email *

How would you like us to contact you regarding your complaint? *
   Phone    Email    Regular mail
What kind of policy is involved? *
   Home    Auto    Commercial

Name of insurance company (not the broker or agent) involved: *
   
Name of broker or agent:
   
Name of policy holder: *
   
Policy or certificate number:
   
Who did you contact about your complaint?
   
This person works at the:
   Brokerage/agency Insurance company
Date of the contact?
Anyone else?
Have you contacted a lawyer? * Yes No

Please proivide a summary of the problem: *
   
Is there anything else we should know about your dispute with your insurance company?
   

   A General Insurance OmbudService Consumer Services Officer from your region will contact you
   within two working days of receiving this submission

I hereby authorize GIO to help me settle my dispute with my insurer by:

  • checking the above personal information with the insurance company whose name appears on this form; and
  • obtaining from the insurance company and/or my broker any other missing personal information relevant to this file and sharing this information within GIO.
  • I acknowledge and agree that the provision of personal information constitutes my consent to its collection, use and disclosure by General Insurance OmbudService (GIO).

    I understand that the collection, use and limited disclosure of any personal information will only be for the purpose of resolving the dispute outlined above, and only in a manner consistent with GIO’s Privacy and Confidentiality Policy, a copy of which is available to me at www.gio-scad.org.

    Subject to applicable laws and with specific exceptions to protect the privacy of third parties, I understand that I may access my personal information and have it amended as appropriate.


      
    * = Required

    Insurance OmbudService - dispute resolution, conflict resolution and more from General Insurance OmbudService. Consumer mediation - conflict resolution, dispute resolution, Insurance ombudservice.