Fillable Business Activity Complaint Form (Collège Boréal)

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Business Activity Complaint Form (Collège Boréal)

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The Business Activity Complaint Form (Collège Boréal) form is 3 pages long and contains:

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  • 27 check-boxes
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Country of origin: CANADA
File type: PDF

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FSCO 1391E (2018-09-01)
© Queen's Printer for Ontario, 2018
Business Activity Complaint Form
Business Activity Complaint Form
Financial Services
Commission
of Ontario
Instructions
To assist our review please complete and sign the form ensuring you have included the final position/response letter
provided by the individual/entity and any relevant information and facts that support your complaint. You may attach a
separate letter and other related documents. Please note that a review of your complaint may be delayed if you have not
included the final position/response letter. Please send this form and your supporting documentation to the attention of
the “Market Regulation Branch” by regular mail to the address found in the Notification and Consent section, by fax to
416 590-8480, or by email to contactcentre@fsco.gov.on.ca
General Information
Last Name First Name Middle Initial
Street Address
Unit Number Street Number Street Name
City/Town Province Postal Code
Telephone Number
ext.
Fax Number Email Address
Preferred method of contact
Phone Email Letter
Complaint Information
Who is your complaint with? (select one)
Credit Union/Caisse Populaire
Insurance Company
Insurance Agent/Adjuster
Mortgage Administrator
Mortgage Agent/Broker
Mortgage Brokerage
Mortgage Lender
Health Service Provider
Other,
specify
What is your complaint about? (select one)
Accident and Sickness Insurance
Automobile Insurance
Disability Insurance
Insurance Investments
Life Insurance
Mortgage
Medical Treatment/Rehabilitation
Property Insurance
Other,
specify
FSCO 1391E (2018-09-01)
© Queen's Printer for Ontario, 2018
Business Activity Complaint Form
The complaint is against the following individual/entity
Individual Name (if applicable) Claim/Policy/Licence/Reference No.
Entity Name (if applicable)
Street Address
Unit Number Street Number Street Name
City/Town Province Postal Code
Telephone Number
ext.
Fax Number Email Address
Complaint Details
The date when you first became aware of the circumstances giving rise to your complaint (yyyy/mm/dd)
Describe the nature of your complaint. Include facts and supporting documents where possible.
Use a separate attachment if necessary.
Please provide the name and contact information of the person you attempted to resolve the matter with:
Name of Contact Email Address Telephone Number
ext.
Brief details of steps you have taken to date in order to resolve the matter.
Final Position/Response
I have attached the final position/response letter
I have not attached the final position/response letter
If you have not attached the final position/response letter, explain why.
FSCO 1391E (2018-09-01)
© Queen's Printer for Ontario, 2018
Business Activity Complaint Form
Legal Action
Have you commenced legal action?
Yes No
If yes, explain.
Notification and Consent
Personal information provided on this form is being collected by the Financial Services Commission of Ontario (“FSCO”)
under the authority of the Financial Services Commission of Ontario Act, 1997, S.O. 1997, c. 28, s. 3(a) as part of
FSCO’s role as a financial services regulator to protect public interest. Your personal information is necessary to review
and/or investigate the matters in your complaint.
FSCO may need to disclose your information to third parties as part of its review or investigation. By signing below, you
consent to FSCO disclosing the information contained on this form, and any additional information that you supply about
your complaint, to the following parties:
1. The individual(s) and or entity(ies) named in your complaint;
2. Any government ministry, agency, board or commission;
3. Any self-regulatory agency or association; and
4. Any Canadian law enforcement agency.
If you have any questions about FSCO’s collection and disclosure of your personal information, please contact:
Financial Services Commission of Ontario
5160 Yonge Street, Box 85
Toronto, ON M2N 6L9
Telephone: (416) 250-7250
Toll Free: 1-800-668-0128
Fax: (416) 590-8480
TTY: 1-800-387-0584
Email: contactcentre@fsco.gov.on.ca
I hereby authorize the Financial Services Commission of Ontario to disclose the information I have submitted about my
complaint, including my personal information, to the individual(s) and/or entity(ies) named in my complaint; to any
government ministry, agency, board or commission; to any self-regulatory agency or association; and to any Canadian
law enforcement agency as may be required for the purposes of further reviewing or investigating my complaint.
I decline to authorize the disclosure of the information I have submitted about my complaint.
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Business Activity Complaint Form (Collge Boral)

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Completed 3 February 2021

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