2412 Kaladar Ave. Ottawa, Ontario K1V 8C1
Tel: (613) 526-1184 Fax: (613) 526-4974
info@trigoninsurance.com

Personal Information Complaint Form

Client Name: ______________________________
Address: ______________________________
Telephone Number: ______________________________
Fax (if any): ______________________________
Email Address (if any): ______________________________

Insurer (if known): ______________________________
Policy Number (if known): ______________________________

(Please briefly state the nature of your complaint):

______________________________ 		______________________________

Signature of Client					Date Signed 

FOR OFFICE USE ONLY:
Date Received: ___________________________ By (Print Name): ______________________________
Date acknowledged: ___________________________ By (Print Name): ______________________________
Date of response: ___________________________ By (Print Name): ______________________________