Complaint Form

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Please Complete the Following Information.

* Mandatory Information Required

* First Name:

* Last Name:

* Email:

* Daytime Phone:

* Address:

Suite/Apt:

* City:

* Province:

* Postal Code:

Insurance Company Name:

Details of problem:

Please write a maximum 20 line summary of your complaint, including the reason for your dissatisfaction and your expectations.

An OLHI Complaints Counsellor will contact you within three business days of receiving this submission. By submitting this form, I hereby authorize OLHI and its representatives to assist me with 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 OLHI.

I acknowledge and agree that the provision of personal information constitutes my consent to its collection, use and disclosure by OLHI and its representatives in accordance with OLHI’s Privacy Statement. I further 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 for statistical reporting on an aggregate basis only in a manner consistent with OLHI’s Privacy Statement.
Click Here for OLHI’s Privacy Statement.

I further understand and agree that OLHI’s process is confidential and without prejudice and that I will not disclose to anyone, including any court, legal or administrative body, or the media, anything said in OLHI’s process or the outcome of the process. I further understand OLHI will not discuss my case with the media, even with my consent, and that the files and records made or complied by OLHI or its representatives in connection with my complaint are confidential and proprietary to OLHI and will not be provided directly or indirectly to the parties involved or to any third parties. I also agree that I will not subpoena, summons or otherwise require OLHI or its representatives to testify with respect to any matter pertaining to OLHI’s process or to produce any files or records made or complied by OLHI or its representatives in connection with my complaint in any current or future legal proceedings.

By submitting this form I hereby agree to the above terms, including the terms of OLHI's Privacy Statement.