FSCO 1391E (2018-09-01) © Queen's Printer for Ontario, 2018
Business Activity Complaint Form
Business Activity Complaint FormFinancial Services Commission of
Ontario
InstructionsTo 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
[email protected]
General InformationLast Name First Name Middle Initial
Street AddressUnit Number Street Number Street Name
City/Town Province Postal Code
Telephone Numberext.
Fax Number Email Address
Preferred method of contact
Phone Email Letter
Complaint InformationWho 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
mailto:[email protected].
FSCO 1391E (2018-09-01) © Queen's Printer for Ontario, 2018
Business Activity Complaint Form
Legal ActionHave you commenced legal action?
Yes No
If yes, explain.
Notification and ConsentPersonal 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:
[email protected]
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.
Name (please print) Date (yyyy/mm/dd)
mailto:[email protected]
Instructions�General Information�Complaint Information�The
complaint is against the following individual/entity�Complaint
Details�Final Position/Response�Legal Action�Notification and
Consent�
FSCO 1391E (2018-09-01)
© Queen's Printer for Ontario, 2018
Business Activity Complaint Form
Business Activity Complaint Form
Financial Services
Commission
of Ontario
Ontario Coat of Arms
S:\Sharinf2\PUBLIC AFFAIRS\FORMS\FSCO form inventory\COA.gif
Instructions
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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 [email protected]
General Information
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General Information
Street Address
Preferred method of contact
Complaint Information
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Complaint Information
Who is your complaint with? (select one)
What is your complaint about? (select one)
The complaint is against the following individual/entity
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The complaint is against the following individual/entity
Street Address
Complaint Details
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Complaint Details
Please provide the name and contact information of the person
you attempted to resolve the matter with:
Final Position/Response
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Final Position/Response
Legal Action
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Legal Action
Have you commenced legal action?
Notification and Consent
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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: [email protected]
11.0.0.20130303.1.892433.887364
Sep 2018
FSCO
Business Activity Complaint Form
Form number 1391E
General Information. Postal Code.Enter Postal Code in format:
letter, digit, letter, digit, letter, digit.
The complaint is against the following individual or entity.
Postal Code.Enter Postal Code in format: letter, digit, letter,
digit, letter, digit.
Complaint Details. The date when you first became aware of the
circumstances giving rise to your complaint.Enter date in format:
year: 4 digits, month: 2 digits, day: 2 digits. Or select date from
the drop down calendar (press down arrow to open the calendar, use
the arrow keys to navigate by keyboard)
Notification and Consent. Date.Enter date in format: year: 4
digits, month: 2 digits, day: 2 digits. Or select date from the
drop down calendar (press down arrow to open the calendar, use the
arrow keys to navigate by keyboard)
General Information. Last Name: General Information. First Name:
General Information. Middle Initial: The complaint is against the
following individual or entity. Street address. Unit Number: The
complaint is against the following individual or entity. Street
address. Street Number: The complaint is against the following
individual or entity. Street address. Street Name: The complaint is
against the following individual or entity. City or Town: The
complaint is against the following individual or entity. Province:
postalCode: Please provide the name and contact information of the
person you attempted to resolve the matter with. Telephone Number:
Please provide the name and contact information of the person you
attempted to resolve the matter with. Telephone Number Extension:
The complaint is against the following individual or entity. Fax
Number: Please provide the name and contact information of the
person you attempted to resolve the matter with. Email Address:
Legal Action. Have you commenced legal action? Yes: Legal Action.
Have you commenced legal action? No: General Information. Preferred
method of contact. Letter: Complaint Information. What is your
complaint about? (select one) Accident and Sickness Insurance:
Complaint Information. What is your complaint about? (select one)
Automobile Insurance: Complaint Information. What is your complaint
about? (select one) Disability Insurance: Complaint Information.
What is your complaint about? (select one) Insurance Investments:
Complaint Information. What is your complaint about? (select one)
Life Insurance: Complaint Information. What is your complaint
about? (select one) Mortgage: Complaint Information. What is your
complaint about? (select one) Medical Treatment or Rehabilitation:
Complaint Information. What is your complaint about? (select one)
Property Insurance: Complaint Information. What is your complaint
about? (select one) Other, specify: Notification and Consent. I
decline to authorize the disclosure of the information I have
submitted about my complaint.: The complaint is against the
following individual or entity. : The complaint is against the
following individual or entity. Claim or Policy or License or
Reference No.: The complaint is against the following individual or
entity. Entity Name (if applicable): date: Complaint Details.
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: Complaint
Details. Brief details of steps you have taken to date in order to
resolve the matter.: Legal Action. If yes, explain.: Notification
and Consent. Name (please print): Print Form: EmailSubmitButton1:
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