DATA FORMAT FOR REGESTERING COMPLAINT

*Name of Complainant

Communication Details

*Door No./ Bldg/Name/ Floor

Street / Area

*City/Town/Panchayath/Village

Taluk/Tehzil

District

*State

*Pin Code

E- Mail

Telephone No

*Mobile No

Fax No

*Insurance Type (Please mentioned Insurance Type

*Life

* Non Life

*Insurance Company Name

*Date of Birth of Policy Holder

*Policy No:

Cover Note:

Other Reference No:

Policy serving Brach Code/Address

*Details of the Complaint (Please type the full details of the complaint)

*Have you Approached Insurance Company Regarding This Grievance (If Yes Provide Ref No )
* Mandatory Fields

Mr./Ms.neelesh bansal

house no 60

sector 12 vasundhara

Ghaziabad

ghaziabad

Uttar Pradesh

201012

neelesh.bansal@gmail.com

1202755002

9999497111

Travel Insurance

Royal Sundaram

3/12/1954
TLI0098981000100
Neelesh Bansal Proposer for Ajay Kumar Bansal

1196091