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.S.S.K.Suryanarayana.Toleti

503, Sukruth Avaas,

Mitra Hills, Hyder Nagar

Hyderabad

Telangana

500085

Surya.toleti@gmail.com

91-9032033223

Life

Bharti AXA

8/17/1986

503-3570796
Insurer is not responding/denying for ECS(Auto debit)removal

Yes via email/customer care/branch visit