Please Complete the Following Information

Last Name:  
First Name:  

E-mail:  
Business Telephone:  
Ext *numeric values only*
Cell Phone:  
*numeric values only*
Home Telephone:  
*numeric values only*

Address:  
Suite/Apt: 

City:  
Province:  
Postal Code:  

Insurance Company Name:  

Details of Problem:  


A General Insurance OmbudService Consumer Service Officer from your region will contact you within one working day of receiving this submission

By submitting this form, I hereby authorize GIO to help me settle my dispute with my insurer by:
  • checking the above personal information with the insurance company whose name appears on this form; and
  • obtaining from the insurance company and/or my broker any other missing personal information relevant to this file and sharing this information within GIO.

I acknowledge and agree that the provision of personal information constitutes my consent to its collection, use and disclosure by General Insurance OmbudService (GIO).

I understand that the collection, use and limited disclosure of any personal information will only be for the purpose of resolving the dispute outlined above, and only in a manner consistent with GIO’s Privacy and Confidentiality Policy, a copy of which is available to me at http://www.giocanada.org/pstatement.

Subject to applicable laws and with specific exceptions to protect the privacy of third parties, I understand that I may access my personal information and have it amended as appropriate.