Complaint Form

Complaint Form

Before you complete and submit the complaint form below, read the information on the Making a Complaint webpage, so you are familiar with the types of issues that RIBO can regulate and investigate.

*" indicates required fields

Consent

Number

In the course of assisting you with your complaint, we will be capturing information related to your situation. Please review our Consent Disclosure and confirm your consent below.

I hereby authorize the Registered Insurance Brokers of Ontario (RIBO) 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*

PLEASE NOTE: Declining to authorize the disclosure of information on your behalf will entirely eliminate our ability to assist you with your complaint.

Contact Details

Are you the named insured (policyholder) or are you acting on behalf of someone?*

Your Name*

First Last

Your Email*

Your Phone Number*

Name of Person Lodging Complaint*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please advise if your are a consumer, broker, lawyer or other party*

Please confirm is this complaint is with an individual broker or with a brokerage*

Broker Details

What is the full name of the Individual Broker?*

Please confirm the brokerage they work for*

Employer Brokerage License

Brokerage Details

What is the name of the brokerage this is related to?*

Brokerage License

What is the full name of the broker you dealt with?*

Incident Details

Brokerage Location*

City Province

Which insurance company is this related to?*

When did the incident occur?*

What Type of Insurance is this related to?*

Please provide specifics on the type of insurance this is related to*

Policy Number(s) (If Available)

Complaint Details

Please confirm what sort of issue this is*

Details of the matter (1,000 characters max.)*

Supporting documents to your allegations are required. Please attach using the "Select file" button below:

Drop files here or

Accepted file types: pdf, ppt, doc, pptx, docx, Max. file size: 256 MB, Max. files: 3.

Do you have a link for the brokerage website?

Have you escalated this matter with the broker or within the brokerage?*

Please confirm the name of who you dealt with

First Last

Please confirm what their response was below*

Have you referred this matter to another regulating organization?*

Please confirm which regulating organization*

Please provide details of your escalation with them*

Please confirm what sort of resolution you are seeking*

I have read and agree to the Terms & Conditions including the Privacy Policy

Please confirm you reviewed the Terms & Conditions and Privacy Policy*

Yes, I confirm I have reviewed the Terms & Conditions and Privacy Policy

Your eSignature confirming all of the above*

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Consent

Contact Details

Broker Details

Brokerage Details

Incident Details

Complaint Details

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