Fillable Printable Financial Ombudsman Service Complaint Form - Bureau
Fillable Printable Financial Ombudsman Service Complaint Form - Bureau
Financial Ombudsman Service Complaint Form - Bureau
Ombudsman um Sheirbhísí Airgeadais
Financial Services Ombudsman
FSOB Complaint Form
1
Please be aware that this is an important document for the handling of your complaint.
Please ensure the Form is filled in correctly before forwarding to this office.
Section A:
Please give us your details and the details of anyone complaining with you - PLEASE FILL IN BLOCK CAPS
Complainant 1
Title: Mr./Mrs./Ms./Other (please state)
Full Name:
Occupation:
Date of Birth:
Daytime Phone:
Mobile:
Do you require any special assistance
(e.g. hearing or vision impairment)
if yes, please specify
M F
D D M M Y Y Y Y
Yes No
Complainant 2
Title: Mr./Mrs./Ms./Other (please state)
Full Name:
Occupation:
Date of Birth:
Daytime Phone:
Mobile:
Do you require any special assistance
(e.g. hearing or vision impairment)
if yes, please specify
M F
D D M M Y Y Y Y
Yes No
2
If you have asked SOMEONE ELSE (e.g. a professional advisor or relative) TO
COMPLAIN TO US ON YOUR BEHALF, please give their details here. Please note that
all future correspondence will be sent to this person on your behalf and not your
address listed above. Please read notice in Section E.
Name:
Address:
Professional advisor other
Phone Number:
E-mail:
(Please confirm, by ticking the appropriate answer, if you prefer to be
contacted by email.
Note,
only routine letters will be sent by email, any
personal documentation will be sent by post)
Yes No
Address for correspondence:
Email for correspondence:
(Please confirm, by ticking the appropriate answer, if you prefer to be
contacted by email.
Note,
only routine letters will be sent by email,
any personal documentation will be sent by post)
Yes No
Business Name:
Are you a: (please tick one box)
Sole trader
Limited Company
Partnership
Other (please state)
If you ticked any of the above mentioned boxes please provide audited accounts which
confirm the annual turnover for the financial year prior to which the complaint is made to
Financial Services Ombudsman. The Bureau will need evidence from you about this figure. If
the figure is more than €3 million, the Bureau will not be able to examine your complaint.
Section B:
If you are complaining on behalf of a business:
Section C:
Details of Financial Service Provider(s) (e.g. Bank, Insurance Company, Broker, etc)
you are complaining about
Financial Service Provider Name(s):
Name & Type of Product / Service you are complaining about
(e.g Mortgage, Life Insurance Policy, Investment, etc):
Account or Policy number:
When was the product sold?: (if you cannot provide the precise date, please clarify the month
and year)
When did the advice, service or transaction you’re complaining about take place:
(if you cannot provide the precise date, please clarify the month and year)
(Please note that time limits may apply, for instance we are not permitted to examine your
complaint if the conduct complained of occurred over 6 years ago)
Has the product been sold to you by a person other than the
Financial Service Provider named above?
If so, please provide name and details of that provider or person.
D D M M Y Y Y Y
D D M M Y Y Y Y
Yes No
3
Please describe the complaint in your own words
(you may use bullet points, or a separate sheet if necessary).
How do you want the Financial Service Provider to put things right?
If you are seeking payment of a sum of money please provide any relevant calculations.
4
Section D:
Your Complaint
If your complaint relates to medical issues please note that in the course of an
investigation this office may receive medical evidence from the Provider which
may contain sensitive detail.
If you do not wish this medical evidence to be sent directly to you (or if you have
completed Section A, if you do not wish this medical evidence to be sent to your
nominated representative) you have the option to instruct this office to send it
instead to a nominated medical professional, by ticking this box and completing
the section below to identify your nominated medical professional.
Please send medical evidence to my nominated medical professional
Nominated Medical Professional to whom medical evidence may be sent:
Name:
Address:
Phone Number:
5
Section E:
Medical Evidence
Section F:
Final Checklist
(please tick the relevant option)
6
Have you reviewed the notice on Medical Evidence at Section E ?
YES NO
Have you given your occupation? (Section A)
YES NO
Have you confirmed when the policy/product was sold and
YES NO
who it was sold by (Section C)
Have you described your complaint and desired resolution
YES NO
in your own words? (Section D)
Is, or has, your complaint been the subject of legal proceedings,
YES NO
before a court or tribunal, or are legal proceedings pending?
If you have answered YES, please give details:
Has your complaint been subject to Arbitration previously?
YES NO
Is the dispute between you and any other person
YES NO
other than the Financial Service Provider?
Have you attached a copy of all relevant documentation from
YES NO
the Financial Service Provider which supports your complaint?
Have you ever registered a complaint with the FSOB before?
YES NO
If ticking YES - Ref No: .......................................
We may, from time to time, contact you to carry out surveys
YES NO
or questionnaires with regard to our service.
Please confirm if you are happy to partake in such surveys.
7
Biúró an Ombudsman um Sheirbhísí Airgeadais
Urlár 3, Teach Lincoln, Plás Lincoln, Baile Átha Cliath 2
Financial Services Ombudsman’s Bureau
3rd Floor, Lincoln House, Lincoln Place, Dublin 2
Íos-ghlao/Lo-Call: 1890 88 20 90 Teil/Tel: + 353 (1) 6620899 Faics/Fax: + 353 (1) 6620890
Riomhphost/Email: xxx xxx
Láithreán gréasáin/Website: xxx xxx
Section G:
Declaration
The Financial Services Ombudsman Bureau will treat all information submitted in
accordance with the purposes registered under the Data Protection Acts 1988 &
2003.
YOUR PERMISSION TO GO AHEAD
I would like the Financial Service Ombudsman’s Bureau to consider my complaint.
I understand that:
You will need to handle personal details about me, which could include
sensitive information (e.g. relating to health, employment, financial
matters etc), in order to deal with my complaint effectively
You will exchange information about my complaint with the Financial
Service Provider and where appropriate with my/our nominated medical
professional
You may publish examples, based on real cases, but without mentioning
the identities of those involved
Signature Complainant 1:
Date:
Signature Complainant 2:
Date:
You need to sign here, even if someone else is complaining on your behalf.
If the dispute concerns a policy or account which is in joint names, this Form
must be signed by both holders.
D D M M Y Y Y Y
D D M M Y Y Y Y
