Consumer Complaints Manager - Complaint form v2 _2010_ by qingyunliuliu

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									                                                               MFSA Reference:


                              CONSUMER COMPLAINTS OFFICE

                                            Complaint form
This is the form you need to fill in if you want the Consumer Complaints Manager to look at
your complaint. Remember – you must have complained to the financial services product
provider or other licence holder first. For help to fill in this form, please phone us free on
80074924.


We can help if you need information in a     You can download this form from our website
different format. If you have any special    http://mymoneybox.mfsa.com.mt to complete by hand.
needs, please phone us on 800 74924.         Alternatively, you can fill it on screen – then print it off and mail
                                             it back to us. Sorry but we cannot accept forms submitted by e-
                                             mail.




                                                                             DETAILS OF ANYONE
                                  YOUR DETAILS
                                                                           COMPLAINING WITH YOU
Surname                                       Title                                              Title
First name(s)
ID /Passport No.
Address for
correspondence
(include
postcode)

Daytime phone                                                      Mobile
Home phone                                                         Email




IF SOMEONE IS COMPLAINING ON YOUR BEHALF (EG. A LAWYER OR RELATIVE)
PLEASE GIVE THEIR DETAILS


Their name                                                         Relationship to you
Their address for
correspondence
(include
postcode)
Daytime phone                                                      Fax
Email                                                              Mobile.



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DETAILS OF THE PRODUCT PROVIDER OR LICENCE HOLDER YOU ARE COMPLAINING
ABOUT (This may be your bank, insurance company, life insurance company, fund management company,
stockbroker, investment services licence holder or financial institution)

Name of the Product
Provider or Licence
Holder
Address
(include postcode)



Phone number/s



Your account number &
sort code or policy
number or claim number
or other reference




DETAILS OF THE INTERMEDIARY, ENTITY OR OTHER LICENCE HOLDER WHO ORIGINALLY
SOLD THE PRODUCT OR SERVICE YOU ARE COMPLAINING ABOUT (IF DIFFERENT FROM THE
ENTITY NAMED ABOVE) - (This may be your bank, stockbroker, investment services licence holder,
financial institution, insurance broker, insurance agent, or insurance sub-agent)

Their name
Their address
(include postcode)


Their phone number



LIST THE NAME OF THE PERSON OR PERSONS WHOM YOU HAVE CONTACTED AT THE
INTERMEDIARY, ENTITY OR OTHER LICENCE HOLDER


Name (and surname)
Name (and surname)



DESCRIPTION OF THE PRODUCT OR SERVICE YOU ARE COMPLAINING ABOUT

Please give the name and
type of account, policy etc




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                                                                            Day         Month         Year
 When did the advice, transaction or poor service that
  you are complaining about take place?

                                                                            Day         Month         Year
 When did you first notice that there might be a problem?

                                                                            Day         Month         Year

 When did you first complain to the product provider or
  intermediary?

   Has the product provider or other licence holder sent you
    its final decision on your complaint in writing?                                  YES              NO
     If you have answered YES, please send us a copy of the final response letter from the product provider
      or other licence holder with this form


 Have there been any court/tribunal/arbitration proceedings
  relating to your complaint – or are any                                            YES *             NO
  court/tribunal/arbitration proceedings planned?

 Have you contacted any other authority about your complaint?                       YES *             NO

*If you have answered YES to either of these questions, please give details here:




SUMMARY OF YOUR COMPLAINT
If you need more space to describe your complaint, use a different sheet.




                                                   Page 3
WE ALSO NEED TO KNOW….

   How would you like the product provider or other licence holder you are complaining
    about to put the matter right for you?




YOUR PERMISSION FOR THE CONSUMER COMPLAINTS OFFICE TO GO AHEAD

I would like the Consumer Complaints Manager, or his representative, to consider my
complaint. I confirm that :

   I have read and understood the way the Consumer Complaints Manager at MFSA
    operates and the extent to which the MFSA may help me with my complaint;

   The MFSA has my authorisation to contact the financial entity with whom I have a
    dispute and to request copies of any documentation relating to my complaint;

   You will need to handle personal details about me, which could include sensitive
    information (for example, about health matters), in order to deal with my complaint
    effectively;

   You may need to exchange information about my complaint with other persons or
    organisations in connection with my complaint, if the MFSA deems appropriate to do
    so. In this respect, I am extending my full consent to the Authority to contact such




                                           Page 4
    other persons or organisations, and for such persons or organisations to disclose
    whatever information is required in respect of my/our complaint;

   You handle complaints in a different way from the courts, not usually requiring
    people to attend hearings in person but resolving disputes by
    correspondence/meetings;

   MFSA may use the facts in my complaint as an example of where things can go
    wrong, but it will always respect my privacy and keep my personal information
    strictly confidential except as authorised above.

   I hereby certify and confirm that to the best of my knowledge, the information
    furnished above is true, accurate, correct and complete.
COMPLAINANTS ARE REQUESTED TO SIGN HERE – EVEN IF SOMEONE ELSE IS COMPLAINING
ON YOUR BEHALF.




__________________             __________              __________________          __________
signature                      date                    signature                   date

Name: _________________________                        Name: _________________________




__________________             __________              __________________          __________
signature                      date                    signature                   date

Name: _________________________                        Name: _________________________




FINALLY, HAVE YOU …                   MAIL TO …
                                                   Consumer Complaints Manager
   Included everything you want to               Malta Financial Services Authority
    tell us about your complaint?                          Notabile Road
   Enclosed a copy of the entity’s                       Attard BKR 3000
    final response letter?                                     Malta
   Enclosed copies of relevant          Freephone: 80074924         General: +356 2144 1155
    documents?                          Fax: +356 2144 1189        consumerinfo@mfsa.com.mt

                                                   http://mymoneybox.mfsa.com.mt




                                              Page 5

								
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