Insurance Regulatory and Development Authority
GENERAL INSURANCE & HEALTH
POLICY HOLDER COMPLAINTS REGISTRATION FORM
(Separate forms to be used for each complaint)
Annexure II
Please approach your Insurance Company first with the grievance. If you have not received a response or you are not satisfied with the response on your grievance, you may use this form to register the complaint with IRDA.
If the complaint is a dispute in regard to premium paid or payable, dispute on policy wording pertaining to claim payment, delay in settlement in claims or non-issue of insurance document the same may be lodged with Insurance Ombudsman. The addresses of the Ombudsmen are available on our website.
1. Name of the complainant: ___________________________________________
2. Address of the complainant: ___________________________________________
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3. E-mail/Telephone/Fax: ____________________________
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4. Whether Individual /Company:
(Please tick)
Individual /Company/other entities
5. Name of the Insurance company:___________________________
6. Address of the servicing office/branch with office code (if available):
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________________________________________
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7. Policy number/Proposal deposit number:
8. Nature of complaint: (Please tick)
Policy related
Fire Insurance
Marine Insurance
Motor Insurance
Insurance Regulatory and Development Authority
GENERAL INSURANCE & HEALTH
POLICY HOLDER COMPLAINTS REGISTRATION FORM
(Separate forms to be used for each complaint)
Health Insurance
(a) Against company
(b) Against TPA
Other Misc Insurance
Non-settlement of claim
Fire Insurance
Marine Insurance
Motor Insurance
Health Insurance
(a) Against company
(b) Against TPA
Other Misc Insurance
Repudiation of claim/dispute in
quantum
Fire Insurance
Marine Insurance
Motor Insurance
Health Insurance
A) Against Company
B) Against TPA
Other Misc Insurance
Others
10. Details of complaint (including details of document copies attached):
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SIGNATURE: ________________________
DATE: