Mediation Registration Form

Fill out our form below:

Policyholder

First Name

Last Name

Address

Address Line 1

Province

Postal Code

Phone/Mobile

Email

What kind of policy is involved?

Home

Auto

Commercial

Farm

Name of Insurance Company involved? (not the broker or agent)

Policy Number :

Have you contacted your insurance company's Ombudsman Liaison Officer about this issue?

Yes

No

Have you received from your insurance company's Ombudsman Liaison Officer a letter detailing the final position of your insurer?

Yes

No

Have you initiated legal proceedings on this issue?

Yes

No

What is the dispute related to?

A Claim

Insurance coverage

Other

Specify

Date / Time

MICO

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