FORMAT FOR LODGING GRIEVANCE/COMPLAINT

1
NAME ( IN CAPITAL)
2
DATE OF BIRTH
3
SEX (Please tick)
Male | | Female | | Others | |
4
PAN CARD NO./VOTER ID CARD NO./
PASSPORT NO/RATION CARD NO.(ANY ONE)
5
ADDRESS FOR COMMUNICATION
6
OCCUPATION
7
DESIGNATION (IF IN SERVICE)
8
MOBILE NUMBER AND LAND LINE(ANY ONE)
9
E-MAIL ID
10
NATURE OF COMPLAINT(PLEASE TICK)
DELAY IN ISSUING POLICY
DELAY IN SETTLEMWENT OF CLAIM
REPUDIATION /REJECTION OF CLAIM
DISPUTE IN QUANTUM
OTHERS IF ANY ( PLEASE SPECIFY)
11
DETAILS OF COMPLAINT
12
POLICY NUMBER AND PERIOD
13
CLAIM NUMBER
14
DATE OF LOSS
15
NAME AND ADDRESS OF
POLICY ISSUING OFFICE
16
ANY OTHER REFERENCES
17
WHETHER ANY CORRESPONDENCE/
REFERENCE MADE EARLIER TO
POLICY ISSUING OFFICE
18
WHETHER THE GRIEVANCE
DEPARTMENT OF THE CONCERNED
R.O. HAS BEEN CONSULTED
( IF NOT DONE SO FAR, WE
SUGGEST FOR THE SAME FOR
OBTAINING SPEEDY RESOLUTION
OF THE GRIEVANCE)
DATE:
PLACE
SIGNATURE:
FOR OFFICE USE ONLY
DATE OF RECEIPT
:
OFFICE OF RECEIPT
:
GRIEVANCE ID NUMBER ALLOTED
:
ACKNOWLEDGEMENT SENT ON
:
NAME AND DESIGNATION OF GRIEVANCE OFFICER:
DATE OF DISPOSAL OF GRIEVANCE :
NOTES
1. PLEASE FILL UP ALL THE COLUMNS - SPECIALLY ITEM NUMBER 1 TO 13.
IALLY ITEM NUMBER 1 TO 15
2. GRIEVANCE FORMAT TO BE ADDRESSED TO THE CONCERNED GRIEVANCE OFFICER
( COVER ENVELOPE MUST BE SUPER- SUBSCRIBE WITH THE ADDRESSES OF
CONCERNED GRIEVANCE OFFICER)
3. THE LETTER SHOULD BE ADDRESSED TO THE POLICY ISSUING OFFICE AS MENTIONED
IN THE POLICY.
FORMAT FOR LODGING GRIEVANCE/COMPLAINT