Fillable Complaint Form Information to be provided (Desjardins Insurace)

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Complaint Form Information to be provided (Desjardins Insurace)

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15398E 2019-06
Information to be provided
To file a complaint with Desjardins Financial Security’s Dispute Resolution Officer please fill out this form to the best of your knowledge and mail it to:
disputeofcer@dfs.ca
Dispute Resolution Ofcer
Desjardins Financial Security
200 rue des Commandeurs
Levis, Quebec G6V 6R2
Processing time
The Dispute Resolution Officer or his staff will contact you or will send you acknowledgement of receipt within five days of receiving your complaint.
Moreover, you will receive the results of the review of your complaint within 90 days of receipt or as soon as the Dispute Resolution Officer has obtained all
the necessary information for this review.
The Dispute Resolution Officer or his staff may want to contact you directly. We ask that you include your e-mail address or telephone number where you may
be reached in the section of the form provided for this purpose.
Assistance
Should you require additional information or assistance to complete this form, please call the office of the Dispute Resolution Officer during our regular
business hours (Easter n Standard Time) at the toll-free number: 1 - 8 7 7 - 83 8 - 8 1 8 5.
Personal information concerning the person filing the complaint
Ms.
M r.
First name Last name
Address (No. and street, apt.)
City Province Country Postal Code
Date of birth (YYYY-MM-DD) Telephone (home)
Yes No
E-mail address Telephone (work) Extension
Personal information concerning the person filing a complaint on behalf of someone else
• Desjardins Financial Security cannot release information concerning one of its clients without his/her authorization, even if this is a family member. To give
us this authorization, our client can complete and send the appropriate Authorization for the Collection and Release of Personal Information to Third Parties
that can be found in the “Problems and Complaints” section of our Web site.
• If you are acting as the insured’s agent/mandatary, guardian/tutor or estate executor/liquidator, you must provide us with a copy of the applicable power
of attorney/mandate, will or notarized document identifying you as such.
Ms.
M r.
First name Last name
Address (No. and street, apt.)
City Province Country Postal Code
Date of birth (YYYY-MM-DD) Telephone (home)
Yes No
E-mail address Telephone (work) Extension
Relationship with the insured (Spouse, parent, child, estate executor/liquidator, agent/mandatary, etc.)
Information to be provided – You may include copies instead of the originals of your documents that you consider pertinent or necessary to the
review of your complaint.
Is it possible to reach you during
the day?
Is it possible to reach you during
the day?
Complaint Form
!
15398E 2019-06
Product-related information
Product name Account, policy or certificate number
Name of company that issued this product
(Desjardins Financial Security, Desjardins Life Assurance, Imperial Life, Laurier Life Insurance, La Sauvegarde, Laurentian Life Assurance, etc.)
Name of policyholder, if this is group insurance or retirement savings plan or a plan taken out by a group (Spouse, employer, labour union, association, etc.)
Name of the caisse or bank branch, if this is insurance sold in a Desjardins caisse or another financial institution
Names of the representative and the company, where applicable, if this is an insurance or savings product sold by a representative
Description of your complaint
Explain the nature of your complaint. Indicate the facts that led to the problem. (If necessary, attach additional pages.)
Previous interventions
Have you already contacted anyone working at Desjardins Financial Security with regards to your present complaint?
If so, please indicate the name of this person and the date you contacted him/her.
Name Date (YYYY-MM-DD)
Your expectations
What results do you expect to obtain?
What solution do you propose?
Please sign and date this form.
x
Signature Date (YYYY-MM-DD)
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Completed 9 February 2021

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