Complaint / Report Submission Form

Complaint / Report Submission Form To "Broker Ins" OOD address: 3 Karnigradska St., 2nd floor Sofia e-mail: office@brokerins.bg tel.: 024224244 Ref. No.: ............ / ......................... Application for Registering a Complaint / Report From ................................................................................................................................................... ................................................................................................................................................................ (full name, if the complainant is an individual, or company name, UIC, and full name of the representative) Address:................................................................................................................................................... Contact phone: .............................................; e-mail:................................................................... Dear Sir/Madam, I would like to file a complaint regarding (brief description of the complaint, including against whom it is directed and what the complainant's request consists of): ................................................................................................................................................................ ............................................................................................................................................................... ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ If the complaint relates to an insurance contract concluded, please indicate: Date the insurance was concluded: ....................................................................................................................................... Type of insurance: ......................................................................................................................................... Policy number: ................................................................................................................................................. City/Office/Employee: ......................................................................................................................... ............................................................................................................................................................... In connection with the above, I am attaching to my complaint copies of the documents in my possession, and I would like to receive an official response at: e-mail: ................................................................................................................................................... Address: ................................................................................................................................................... Attachments: (please describe the documents you are submitting): 1. 2. 3. Date: ............................. 20___ Signature: .........................................