CUSTOMER COMPLAINT FORM

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Salutation *

-- Please Choose -- Mr. Mrs. Ms. PT. CV. UD.

Name *

E-mail *

Account Type *

-- Please Choose -- Individual Company

Company Name *

Reference Number of Type Document *

-- Please Choose -- Policy Contract Invoice Number

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About *

-- Please Choose -- Claim Service System

Risk *

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Subject *

Details *

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Notes: *.png, *.jpg, *.jpeg, *.pdf, *.doc, *.docx, *.xls, *.xlsx, *.ppt, *.pptx, *.eml are allowed, and size must be smaller than 5Mb.

   Disclaimer :

• The information filled in form is true and valid. PT Howden Insurance Brokers Indonesia is not liable to any lawful obligations arising from any false or invalid information in this application form whatsoever, all the false or invalid information will not be processed.
• The client hereby agree to render PT Howden Insurance Brokers Indonesia a right to handle complaint including but not limited to grab data from records, emails, documents, confidential data, and others, liaise with relatable Parties e.g. (Insurer, Adjuster, Legal Advisor, etc) to settled complaint.
• The client hereby released PT Howden Insurance Brokers Indonesia from any material or immaterial damages if eventually, there is no evidence of damages caused by PT Howden Insurance Brokers Indonesia.

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