{"id":1823,"date":"2018-10-31T05:36:28","date_gmt":"2018-10-31T05:36:28","guid":{"rendered":"https:\/\/www.ofso.org.tt\/?page_id=1823"},"modified":"2023-01-20T15:34:13","modified_gmt":"2023-01-20T19:34:13","slug":"complaint-form","status":"publish","type":"page","link":"https:\/\/ofso.org.tt\/index.php\/complaint-form\/","title":{"rendered":"Complaint Form"},"content":{"rendered":"<p>[vc_row row_type=&#8221;row&#8221; stretch_row_type=&#8221;no&#8221;][vc_column width=&#8221;1\/6&#8243;][\/vc_column][vc_column width=&#8221;2\/3&#8243;]<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-1908\"><form id=\"wpforms-form-1908\" class=\"wpforms-validate wpforms-form\" data-formid=\"1908\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/1823\"><div class=\"wpforms-page-indicator connector\" data-indicator=\"connector\" data-indicator-color=\"#72b239\"><div class=\"wpforms-page-indicator-page active  wpforms-page-indicator-page-1\" style=\"width:20%;\"><span class=\"wpforms-page-indicator-page-number\" style=\"background-color:#72b239\">1<span class=\"wpforms-page-indicator-page-triangle\" style=\"border-top-color:#72b239\"><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">1<span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-2\" style=\"width:20%;\"><span class=\"wpforms-page-indicator-page-number\" >2<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">2<span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-3\" style=\"width:20%;\"><span class=\"wpforms-page-indicator-page-number\" >3<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">3<span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-4\" style=\"width:20%;\"><span class=\"wpforms-page-indicator-page-number\" >4<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">4<span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-5\" style=\"width:20%;\"><span class=\"wpforms-page-indicator-page-number\" >5<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">5<span><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \"><div id=\"wpforms-1908-field_115-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"115\"><\/div><div id=\"wpforms-1908-field_39-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"39\"><h3 id=\"wpforms-1908-field_39\" name=\"wpforms[fields][39]\">Step One: Complainant\u2019s Information<\/h3><\/div><div id=\"wpforms-1908-field_4-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_4\">First Name<\/label><input type=\"text\" id=\"wpforms-1908-field_4\" class=\"wpforms-field-large\" name=\"wpforms[fields][4]\" placeholder=\"First Name\" ><\/div><div id=\"wpforms-1908-field_6-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_6\">Last Name<\/label><input type=\"text\" id=\"wpforms-1908-field_6\" class=\"wpforms-field-large\" name=\"wpforms[fields][6]\" placeholder=\"Last Name\" ><\/div><div id=\"wpforms-1908-field_127-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half wpforms-first\" data-field-id=\"127\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_127\">Date of Birth<\/label><select name=\"wpforms[fields][127][date][d]\" id=\"wpforms-field_127-day\" class=\"wpforms-field-date-time-date-day\" ><option class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><option value=\"21\">21<\/option><option value=\"22\">22<\/option><option value=\"23\">23<\/option><option value=\"24\">24<\/option><option value=\"25\">25<\/option><option value=\"26\">26<\/option><option value=\"27\">27<\/option><option value=\"28\">28<\/option><option value=\"29\">29<\/option><option value=\"30\">30<\/option><option value=\"31\">31<\/option><\/select><span class=\"wpforms-field-date-time-date-sep\">\/<\/span><select name=\"wpforms[fields][127][date][m]\" id=\"wpforms-field_127-month\" class=\"wpforms-field-date-time-date-month\" ><option class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><\/select><span class=\"wpforms-field-date-time-date-sep\">\/<\/span><select name=\"wpforms[fields][127][date][y]\" id=\"wpforms-field_127-year\" class=\"wpforms-field-date-time-date-year\" ><option class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2026\">2026<\/option><option value=\"2025\">2025<\/option><option value=\"2024\">2024<\/option><option value=\"2023\">2023<\/option><option value=\"2022\">2022<\/option><option value=\"2021\">2021<\/option><option value=\"2020\">2020<\/option><option value=\"2019\">2019<\/option><option value=\"2018\">2018<\/option><option value=\"2017\">2017<\/option><option value=\"2016\">2016<\/option><option value=\"2015\">2015<\/option><option value=\"2014\">2014<\/option><option value=\"2013\">2013<\/option><option value=\"2012\">2012<\/option><option value=\"2011\">2011<\/option><option value=\"2010\">2010<\/option><option value=\"2009\">2009<\/option><option value=\"2008\">2008<\/option><option value=\"2007\">2007<\/option><option value=\"2006\">2006<\/option><option value=\"2005\">2005<\/option><option value=\"2004\">2004<\/option><option value=\"2003\">2003<\/option><option value=\"2002\">2002<\/option><option value=\"2001\">2001<\/option><option value=\"2000\">2000<\/option><option value=\"1999\">1999<\/option><option value=\"1998\">1998<\/option><option value=\"1997\">1997<\/option><option value=\"1996\">1996<\/option><option value=\"1995\">1995<\/option><option value=\"1994\">1994<\/option><option value=\"1993\">1993<\/option><option value=\"1992\">1992<\/option><option value=\"1991\">1991<\/option><option value=\"1990\">1990<\/option><option value=\"1989\">1989<\/option><option value=\"1988\">1988<\/option><option value=\"1987\">1987<\/option><option value=\"1986\">1986<\/option><option value=\"1985\">1985<\/option><option value=\"1984\">1984<\/option><option value=\"1983\">1983<\/option><option value=\"1982\">1982<\/option><option value=\"1981\">1981<\/option><option value=\"1980\">1980<\/option><option value=\"1979\">1979<\/option><option value=\"1978\">1978<\/option><option value=\"1977\">1977<\/option><option value=\"1976\">1976<\/option><option value=\"1975\">1975<\/option><option value=\"1974\">1974<\/option><option value=\"1973\">1973<\/option><option value=\"1972\">1972<\/option><option value=\"1971\">1971<\/option><option value=\"1970\">1970<\/option><option value=\"1969\">1969<\/option><option value=\"1968\">1968<\/option><option value=\"1967\">1967<\/option><option value=\"1966\">1966<\/option><option value=\"1965\">1965<\/option><option value=\"1964\">1964<\/option><option value=\"1963\">1963<\/option><option value=\"1962\">1962<\/option><option value=\"1961\">1961<\/option><option value=\"1960\">1960<\/option><option value=\"1959\">1959<\/option><option value=\"1958\">1958<\/option><option value=\"1957\">1957<\/option><option value=\"1956\">1956<\/option><option value=\"1955\">1955<\/option><option value=\"1954\">1954<\/option><option value=\"1953\">1953<\/option><option value=\"1952\">1952<\/option><option value=\"1951\">1951<\/option><option value=\"1950\">1950<\/option><option value=\"1949\">1949<\/option><option value=\"1948\">1948<\/option><option value=\"1947\">1947<\/option><option value=\"1946\">1946<\/option><option value=\"1945\">1945<\/option><option value=\"1944\">1944<\/option><option value=\"1943\">1943<\/option><option value=\"1942\">1942<\/option><option value=\"1941\">1941<\/option><option value=\"1940\">1940<\/option><option value=\"1939\">1939<\/option><option value=\"1938\">1938<\/option><option value=\"1937\">1937<\/option><option value=\"1936\">1936<\/option><option value=\"1935\">1935<\/option><option value=\"1934\">1934<\/option><option value=\"1933\">1933<\/option><option value=\"1932\">1932<\/option><option value=\"1931\">1931<\/option><option value=\"1930\">1930<\/option><option value=\"1929\">1929<\/option><option value=\"1928\">1928<\/option><option value=\"1927\">1927<\/option><option value=\"1926\">1926<\/option><option value=\"1925\">1925<\/option><option value=\"1924\">1924<\/option><option value=\"1923\">1923<\/option><option value=\"1922\">1922<\/option><option value=\"1921\">1921<\/option><option value=\"1920\">1920<\/option><\/select><\/div><div id=\"wpforms-1908-field_21-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_21\">Email<\/label><input type=\"email\" id=\"wpforms-1908-field_21\" class=\"wpforms-field-large\" name=\"wpforms[fields][21]\" placeholder=\"youremail@email.com\" ><\/div><div id=\"wpforms-1908-field_9-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_9\">Occupation<\/label><input type=\"text\" id=\"wpforms-1908-field_9\" class=\"wpforms-field-large\" name=\"wpforms[fields][9]\" placeholder=\"Please state your professional title\" ><\/div><div id=\"wpforms-1908-field_126-container\" class=\"wpforms-field wpforms-field-select wpforms-one-third wpforms-first\" data-field-id=\"126\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_126\">ID Type<\/label><select name=\"wpforms[fields][126]\" id=\"wpforms-1908-field_126\" class=\"wpforms-field-large\"  ><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Please select ID type<\/option><option value=\"ID Number\" >ID Number<\/option><option value=\"Driver&#039;s Permit Number\" >Driver's Permit Number<\/option><option value=\"Passport Number\" >Passport Number<\/option><\/select><\/div><div id=\"wpforms-1908-field_16-container\" class=\"wpforms-field wpforms-field-text wpforms-two-thirds\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_16\">ID\/DP\/PP Number<\/label><input type=\"text\" id=\"wpforms-1908-field_16\" class=\"wpforms-field-large\" name=\"wpforms[fields][16]\" ><\/div><div id=\"wpforms-1908-field_18-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_18\">Address<\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-1908-field_18\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][18][address1]\" ><label for=\"wpforms-1908-field_18\" class=\"wpforms-field-sublabel after \">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-1908-field_18-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][18][address2]\" ><label for=\"wpforms-1908-field_18-address2\" class=\"wpforms-field-sublabel after \">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1908-field_18-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][18][city]\" ><label for=\"wpforms-1908-field_18-city\" class=\"wpforms-field-sublabel after \">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1908-field_18-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][18][state]\" ><label for=\"wpforms-1908-field_18-state\" class=\"wpforms-field-sublabel after \">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1908-field_18-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][18][postal]\" ><label for=\"wpforms-1908-field_18-postal\" class=\"wpforms-field-sublabel after \">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-1908-field_18-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][18][country]\" ><option value=\"AF\" >Afghanistan<\/option><option value=\"AX\" >\u00c5land Islands<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MK\" >Macedonia (Republic of)<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SZ\" >Swaziland<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Province of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TR\" >Turkey<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"US\" >United States of America<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Viet Nam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><\/select><label for=\"wpforms-1908-field_18-country\" class=\"wpforms-field-sublabel after \">Country<\/label><\/div><\/div><\/div><div id=\"wpforms-1908-field_15-container\" class=\"wpforms-field wpforms-field-select wpforms-one-third wpforms-first\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_15\">Type of Phone<\/label><select name=\"wpforms[fields][15]\" id=\"wpforms-1908-field_15\" class=\"wpforms-field-large\"  ><option value=\"Mobile\" >Mobile<\/option><option value=\"Work\" >Work<\/option><option value=\"Home\" >Home<\/option><\/select><\/div><div id=\"wpforms-1908-field_19-container\" class=\"wpforms-field wpforms-field-phone wpforms-two-thirds\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_19\">Phone Number<\/label><input type=\"tel\" id=\"wpforms-1908-field_19\" class=\"wpforms-field-large\" name=\"wpforms[fields][19]\" ><\/div><div id=\"wpforms-1908-field_94-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"94\"><div id=\"wpforms-1908-field_94\"><br>\r\n<br>\r\n<br><\/div><\/div><div id=\"wpforms-1908-field_20-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"20\"><h3 id=\"wpforms-1908-field_20\" name=\"wpforms[fields][20]\">Co-complainant\u2019s\/Representative\u2019s Details:<\/h3><div class=\"wpforms-field-description\">The co-complainant is someone who has a joint account\/policy with the complainant. A representative is someone who is submitting a complaint on behalf of someone else.\r\n<br>\r\n<br>\r\n*If there are more than 2 persons making this complaint, please list the details of the other person(s) on a separate sheet of paper and attach it to this Form.<\/div><\/div><div id=\"wpforms-1908-field_17-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"17\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1908-field_17\">Multiple Choice<\/label><ul id=\"wpforms-1908-field_17\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1908-field_17_1\" name=\"wpforms[fields][17]\" value=\"Co-Complainant\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_17_1\">Co-Complainant<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1908-field_17_2\" name=\"wpforms[fields][17]\" value=\"Representative\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_17_2\">Representative<\/label><\/li><\/ul><\/div><div id=\"wpforms-1908-field_25-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_25\">First Name<\/label><input type=\"text\" id=\"wpforms-1908-field_25\" class=\"wpforms-field-large\" name=\"wpforms[fields][25]\" placeholder=\"First Name\" ><\/div><div id=\"wpforms-1908-field_26-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_26\">Last Name<\/label><input type=\"text\" id=\"wpforms-1908-field_26\" class=\"wpforms-field-large\" name=\"wpforms[fields][26]\" placeholder=\"Last Name\" ><\/div><div id=\"wpforms-1908-field_128-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half wpforms-first\" data-field-id=\"128\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_128\">Date of Birth<\/label><select name=\"wpforms[fields][128][date][d]\" id=\"wpforms-field_128-day\" class=\"wpforms-field-date-time-date-day\" ><option class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><option value=\"21\">21<\/option><option value=\"22\">22<\/option><option value=\"23\">23<\/option><option value=\"24\">24<\/option><option value=\"25\">25<\/option><option value=\"26\">26<\/option><option value=\"27\">27<\/option><option value=\"28\">28<\/option><option value=\"29\">29<\/option><option value=\"30\">30<\/option><option value=\"31\">31<\/option><\/select><span class=\"wpforms-field-date-time-date-sep\">\/<\/span><select name=\"wpforms[fields][128][date][m]\" id=\"wpforms-field_128-month\" class=\"wpforms-field-date-time-date-month\" ><option class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><\/select><span class=\"wpforms-field-date-time-date-sep\">\/<\/span><select name=\"wpforms[fields][128][date][y]\" id=\"wpforms-field_128-year\" class=\"wpforms-field-date-time-date-year\" ><option class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2026\">2026<\/option><option value=\"2025\">2025<\/option><option value=\"2024\">2024<\/option><option value=\"2023\">2023<\/option><option value=\"2022\">2022<\/option><option value=\"2021\">2021<\/option><option value=\"2020\">2020<\/option><option value=\"2019\">2019<\/option><option value=\"2018\">2018<\/option><option value=\"2017\">2017<\/option><option value=\"2016\">2016<\/option><option value=\"2015\">2015<\/option><option value=\"2014\">2014<\/option><option value=\"2013\">2013<\/option><option value=\"2012\">2012<\/option><option value=\"2011\">2011<\/option><option value=\"2010\">2010<\/option><option value=\"2009\">2009<\/option><option value=\"2008\">2008<\/option><option value=\"2007\">2007<\/option><option value=\"2006\">2006<\/option><option value=\"2005\">2005<\/option><option value=\"2004\">2004<\/option><option value=\"2003\">2003<\/option><option value=\"2002\">2002<\/option><option value=\"2001\">2001<\/option><option value=\"2000\">2000<\/option><option value=\"1999\">1999<\/option><option value=\"1998\">1998<\/option><option value=\"1997\">1997<\/option><option value=\"1996\">1996<\/option><option value=\"1995\">1995<\/option><option value=\"1994\">1994<\/option><option value=\"1993\">1993<\/option><option value=\"1992\">1992<\/option><option value=\"1991\">1991<\/option><option value=\"1990\">1990<\/option><option value=\"1989\">1989<\/option><option value=\"1988\">1988<\/option><option value=\"1987\">1987<\/option><option value=\"1986\">1986<\/option><option value=\"1985\">1985<\/option><option value=\"1984\">1984<\/option><option value=\"1983\">1983<\/option><option value=\"1982\">1982<\/option><option value=\"1981\">1981<\/option><option value=\"1980\">1980<\/option><option value=\"1979\">1979<\/option><option value=\"1978\">1978<\/option><option value=\"1977\">1977<\/option><option value=\"1976\">1976<\/option><option value=\"1975\">1975<\/option><option value=\"1974\">1974<\/option><option value=\"1973\">1973<\/option><option value=\"1972\">1972<\/option><option value=\"1971\">1971<\/option><option value=\"1970\">1970<\/option><option value=\"1969\">1969<\/option><option value=\"1968\">1968<\/option><option value=\"1967\">1967<\/option><option value=\"1966\">1966<\/option><option value=\"1965\">1965<\/option><option value=\"1964\">1964<\/option><option value=\"1963\">1963<\/option><option value=\"1962\">1962<\/option><option value=\"1961\">1961<\/option><option value=\"1960\">1960<\/option><option value=\"1959\">1959<\/option><option value=\"1958\">1958<\/option><option value=\"1957\">1957<\/option><option value=\"1956\">1956<\/option><option value=\"1955\">1955<\/option><option value=\"1954\">1954<\/option><option value=\"1953\">1953<\/option><option value=\"1952\">1952<\/option><option value=\"1951\">1951<\/option><option value=\"1950\">1950<\/option><option value=\"1949\">1949<\/option><option value=\"1948\">1948<\/option><option value=\"1947\">1947<\/option><option value=\"1946\">1946<\/option><option value=\"1945\">1945<\/option><option value=\"1944\">1944<\/option><option value=\"1943\">1943<\/option><option value=\"1942\">1942<\/option><option value=\"1941\">1941<\/option><option value=\"1940\">1940<\/option><option value=\"1939\">1939<\/option><option value=\"1938\">1938<\/option><option value=\"1937\">1937<\/option><option value=\"1936\">1936<\/option><option value=\"1935\">1935<\/option><option value=\"1934\">1934<\/option><option value=\"1933\">1933<\/option><option value=\"1932\">1932<\/option><option value=\"1931\">1931<\/option><option value=\"1930\">1930<\/option><option value=\"1929\">1929<\/option><option value=\"1928\">1928<\/option><option value=\"1927\">1927<\/option><option value=\"1926\">1926<\/option><option value=\"1925\">1925<\/option><option value=\"1924\">1924<\/option><option value=\"1923\">1923<\/option><option value=\"1922\">1922<\/option><option value=\"1921\">1921<\/option><option value=\"1920\">1920<\/option><\/select><\/div><div id=\"wpforms-1908-field_28-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_28\">Email<\/label><input type=\"email\" id=\"wpforms-1908-field_28\" class=\"wpforms-field-large\" name=\"wpforms[fields][28]\" ><\/div><div id=\"wpforms-1908-field_29-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_29\">Occupation<\/label><input type=\"text\" id=\"wpforms-1908-field_29\" class=\"wpforms-field-large\" name=\"wpforms[fields][29]\" ><\/div><div id=\"wpforms-1908-field_129-container\" class=\"wpforms-field wpforms-field-select wpforms-one-third wpforms-first\" data-field-id=\"129\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_129\">ID Type (copy)<\/label><select name=\"wpforms[fields][129]\" id=\"wpforms-1908-field_129\" class=\"wpforms-field-large\"  ><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Please select ID type<\/option><option value=\"ID Number\" >ID Number<\/option><option value=\"Driver&#039;s Permit Number\" >Driver's Permit Number<\/option><option value=\"Passport Number\" >Passport Number<\/option><\/select><\/div><div id=\"wpforms-1908-field_30-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_30\">ID\/DP\/PP Number<\/label><input type=\"text\" id=\"wpforms-1908-field_30\" class=\"wpforms-field-large\" name=\"wpforms[fields][30]\" ><\/div><div id=\"wpforms-1908-field_31-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_31\">Address<\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-1908-field_31\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][31][address1]\" ><label for=\"wpforms-1908-field_31\" class=\"wpforms-field-sublabel after \">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-1908-field_31-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][31][address2]\" ><label for=\"wpforms-1908-field_31-address2\" class=\"wpforms-field-sublabel after \">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1908-field_31-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][31][city]\" ><label for=\"wpforms-1908-field_31-city\" class=\"wpforms-field-sublabel after \">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1908-field_31-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][31][state]\" ><label for=\"wpforms-1908-field_31-state\" class=\"wpforms-field-sublabel after \">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-1908-field_31-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][31][postal]\" ><label for=\"wpforms-1908-field_31-postal\" class=\"wpforms-field-sublabel after \">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-1908-field_31-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][31][country]\" ><option value=\"AF\" >Afghanistan<\/option><option value=\"AX\" >\u00c5land Islands<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MK\" >Macedonia (Republic of)<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SZ\" >Swaziland<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Province of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TR\" >Turkey<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"US\" >United States of America<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Viet Nam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><\/select><label for=\"wpforms-1908-field_31-country\" class=\"wpforms-field-sublabel after \">Country<\/label><\/div><\/div><\/div><div id=\"wpforms-1908-field_32-container\" class=\"wpforms-field wpforms-field-select wpforms-one-third wpforms-first\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_32\">Type of Phone<\/label><select name=\"wpforms[fields][32]\" id=\"wpforms-1908-field_32\" class=\"wpforms-field-large\"  ><option value=\"Mobile\" >Mobile<\/option><option value=\"Work\" >Work<\/option><option value=\"Home\" >Home<\/option><\/select><\/div><div id=\"wpforms-1908-field_33-container\" class=\"wpforms-field wpforms-field-phone wpforms-two-thirds\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_33\">Phone<\/label><input type=\"tel\" id=\"wpforms-1908-field_33\" class=\"wpforms-field-large wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" name=\"wpforms[fields][33]\" ><\/div><div id=\"wpforms-1908-field_95-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"95\"><div id=\"wpforms-1908-field_95\"><br>\r\n<br>\r\n<br><\/div><\/div><div id=\"wpforms-1908-field_34-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"34\"><h3 id=\"wpforms-1908-field_34\" name=\"wpforms[fields][34]\">Small Business\u2019 Details:<\/h3><div class=\"wpforms-field-description\">If the complainant is a small business, the Form must be completed by someone who is authorized to act for the small business. To be considered a small business, you must attach sound proof that the assets of the business, without its land or buildings, is not valued at more than TT$1.5 million on the date when the complaint occurred. Proof includes audited financial statements or financial statements used for tax purposes.<\/div><\/div><div id=\"wpforms-1908-field_35-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_35\">Name of Business<\/label><input type=\"text\" id=\"wpforms-1908-field_35\" class=\"wpforms-field-large\" name=\"wpforms[fields][35]\" ><\/div><div id=\"wpforms-1908-field_36-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"36\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_36\">Address of Business<\/label><input type=\"text\" id=\"wpforms-1908-field_36\" class=\"wpforms-field-large\" name=\"wpforms[fields][36]\" ><\/div><div id=\"wpforms-1908-field_37-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"37\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_37\">Contact Number of Business<\/label><input type=\"tel\" id=\"wpforms-1908-field_37\" class=\"wpforms-field-large wpforms-masked-input\" data-inputmask=\"&#039;mask&#039;: &#039;(999) 999-9999&#039;\" name=\"wpforms[fields][37]\" ><\/div><div id=\"wpforms-1908-field_38-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_38\">Audited Financials Submitted?<\/label><ul id=\"wpforms-1908-field_38\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1908-field_38_1\" name=\"wpforms[fields][38]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_38_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1908-field_38_2\" name=\"wpforms[fields][38]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_38_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1908-field_114-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"114\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"1908\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" style=\"display:none;\"><div id=\"wpforms-1908-field_22-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"22\"><h3 id=\"wpforms-1908-field_22\" name=\"wpforms[fields][22]\">Step 2: Details of Bank\/Insurance Company<\/h3><\/div><div id=\"wpforms-1908-field_40-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_40\">Name of the Bank\/Insurance Company you have the complaint against:<\/label><input type=\"text\" id=\"wpforms-1908-field_40\" class=\"wpforms-field-large\" name=\"wpforms[fields][40]\" ><\/div><div id=\"wpforms-1908-field_41-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_41\">Branch Address:<\/label><input type=\"text\" id=\"wpforms-1908-field_41\" class=\"wpforms-field-large\" name=\"wpforms[fields][41]\" ><\/div><div id=\"wpforms-1908-field_43-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_43\">Did you receive a claim number or other reference number when you made your complaint?<\/label><ul id=\"wpforms-1908-field_43\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1908-field_43_1\" name=\"wpforms[fields][43]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_43_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1908-field_43_2\" name=\"wpforms[fields][43]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_43_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1908-field_44-container\" class=\"wpforms-field wpforms-field-text wpforms-two-thirds wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"44\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_44\">If yes, state the claim\/reference number: <\/label><input type=\"text\" id=\"wpforms-1908-field_44\" class=\"wpforms-field-large\" name=\"wpforms[fields][44]\" ><\/div><div id=\"wpforms-1908-field_46-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_46\">Did you receive the Bank\u2019s\/Insurance Company\u2019s final decision in writing?<\/label><ul id=\"wpforms-1908-field_46\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1908-field_46_1\" name=\"wpforms[fields][46]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_46_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1908-field_46_2\" name=\"wpforms[fields][46]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_46_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-1908-field_47-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"47\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_47\">Final Decision or Outcome<\/label><textarea id=\"wpforms-1908-field_47\" class=\"wpforms-field-medium\" name=\"wpforms[fields][47]\" ><\/textarea><\/div><div id=\"wpforms-1908-field_48-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-conditional-trigger\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_48\">Please tick the type of complaint:<\/label><select name=\"wpforms[fields][48]\" id=\"wpforms-1908-field_48\" class=\"wpforms-field-large\"  ><option value=\"Bank\" >Bank<\/option><option value=\"Insurance\" >Insurance<\/option><\/select><\/div><div id=\"wpforms-1908-field_49-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"49\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1908-field_49\">Type of Complaint (Bank)<\/label><select name=\"wpforms[fields][49]\" id=\"wpforms-1908-field_49\" class=\"wpforms-field-large\"  ><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Please select one<\/option><option value=\"Accounts and Transactions\" >Accounts and Transactions<\/option><option value=\"Loan Account\" >Loan Account<\/option><option value=\"Card Services\" >Card Services<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-1908-field_51-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"51\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_51\">If other, please specify:<\/label><input type=\"text\" id=\"wpforms-1908-field_51\" class=\"wpforms-field-large\" name=\"wpforms[fields][51]\" ><\/div><div id=\"wpforms-1908-field_50-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"50\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1908-field_50\">Type of Complaint (Insurance)<\/label><select name=\"wpforms[fields][50]\" id=\"wpforms-1908-field_50\" class=\"wpforms-field-large\"  ><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Please select one<\/option><option value=\"Motor Vehicle\" >Motor Vehicle<\/option><option value=\"Property\" >Property<\/option><option value=\"Individual Health\" >Individual Health<\/option><option value=\"Individual Annuity\" >Individual Annuity<\/option><option value=\"Life Insurance\" >Life Insurance<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-1908-field_52-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"52\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_52\">If other, please specify:<\/label><input type=\"text\" id=\"wpforms-1908-field_52\" class=\"wpforms-field-large\" name=\"wpforms[fields][52]\" ><\/div><div id=\"wpforms-1908-field_56-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half wpforms-first\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_56\">Date of incident\/accident:<\/label><input type=\"text\" name=\"wpforms[fields][56][date]\" id=\"wpforms-1908-field_56\" class=\"wpforms-field-large wpforms-field-date-time-date wpforms-datepicker\" placeholder=\"\" data-date-format=\"m\/d\/Y\" ><\/div><div id=\"wpforms-1908-field_57-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_57\">Location:<\/label><input type=\"text\" id=\"wpforms-1908-field_57\" class=\"wpforms-field-large\" name=\"wpforms[fields][57]\" ><\/div><div id=\"wpforms-1908-field_58-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_58\">Registration number of complainant\u2019s vehicle:<\/label><input type=\"text\" id=\"wpforms-1908-field_58\" class=\"wpforms-field-large\" name=\"wpforms[fields][58]\" ><\/div><div id=\"wpforms-1908-field_59-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"59\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_59\">Complainant\u2019s Insurance Company:<\/label><input type=\"text\" id=\"wpforms-1908-field_59\" class=\"wpforms-field-large\" name=\"wpforms[fields][59]\" ><\/div><div id=\"wpforms-1908-field_132-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"132\"><div id=\"wpforms-1908-field_132\"><\/div><\/div><div id=\"wpforms-1908-field_60-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"60\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_60\">Type of insurance coverage:<\/label><ul id=\"wpforms-1908-field_60\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1908-field_60_1\" name=\"wpforms[fields][60]\" value=\"Comprehensive\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_60_1\">Comprehensive<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1908-field_60_2\" name=\"wpforms[fields][60]\" value=\"Third Party\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_60_2\">Third Party<\/label><\/li><\/ul><\/div><div id=\"wpforms-1908-field_92-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"92\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_92\">Please attach a copy of the certified copy of ownership of the motor vehicle to the Form.<\/label><input type=\"file\" id=\"wpforms-1908-field_92\" data-rule-extension=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,xwav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\" data-rule-maxsize=\"52428800\" name=\"wpforms_1908_92\" ><\/div><div id=\"wpforms-1908-field_97-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"97\"><div id=\"wpforms-1908-field_97\"><br>\r\n<br>\r\n<br><\/div><\/div><div id=\"wpforms-1908-field_61-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"61\"><h3 id=\"wpforms-1908-field_61\" name=\"wpforms[fields][61]\">Information on the other vehicle involved in the accident:<\/h3><\/div><div id=\"wpforms-1908-field_62-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third wpforms-first\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_62\">Registration Number:<\/label><input type=\"text\" id=\"wpforms-1908-field_62\" class=\"wpforms-field-large\" name=\"wpforms[fields][62]\" ><\/div><div id=\"wpforms-1908-field_63-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_63\">Owner\u2019s\/Driver\u2019s Name:<\/label><input type=\"text\" id=\"wpforms-1908-field_63\" class=\"wpforms-field-large\" name=\"wpforms[fields][63]\" ><\/div><div id=\"wpforms-1908-field_64-container\" class=\"wpforms-field wpforms-field-text wpforms-one-third\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_64\">Insurance Company:<\/label><input type=\"text\" id=\"wpforms-1908-field_64\" class=\"wpforms-field-large\" name=\"wpforms[fields][64]\" ><\/div><div id=\"wpforms-1908-field_98-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"98\"><div id=\"wpforms-1908-field_98\"><br>\r\n<br>\r\n<br><\/div><\/div><div id=\"wpforms-1908-field_65-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"65\"><h3 id=\"wpforms-1908-field_65\" name=\"wpforms[fields][65]\">In the case of other Insurance or Bank Claim:<\/h3><\/div><div id=\"wpforms-1908-field_66-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half wpforms-first\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_66\">Date of Incident:<\/label><input type=\"text\" name=\"wpforms[fields][66][date]\" id=\"wpforms-1908-field_66\" class=\"wpforms-field-large wpforms-field-date-time-date wpforms-datepicker\" placeholder=\"\" data-date-format=\"m\/d\/Y\" ><\/div><div id=\"wpforms-1908-field_67-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_67\">Insurance Details:<\/label><input type=\"text\" id=\"wpforms-1908-field_67\" class=\"wpforms-field-large\" name=\"wpforms[fields][67]\" ><\/div><div id=\"wpforms-1908-field_69-container\" class=\"wpforms-field wpforms-field-divider wpforms-one-third\" data-field-id=\"69\"><h3 id=\"wpforms-1908-field_69\" name=\"wpforms[fields][69]\">or:<\/h3><\/div><div id=\"wpforms-1908-field_68-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half wpforms-first\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_68\">Date of Incident:<\/label><input type=\"text\" name=\"wpforms[fields][68][date]\" id=\"wpforms-1908-field_68\" class=\"wpforms-field-large wpforms-field-date-time-date wpforms-datepicker\" placeholder=\"\" data-date-format=\"m\/d\/Y\" ><\/div><div id=\"wpforms-1908-field_70-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_70\">Bank Details:<\/label><input type=\"text\" id=\"wpforms-1908-field_70\" class=\"wpforms-field-large\" name=\"wpforms[fields][70]\" ><\/div><div id=\"wpforms-1908-field_117-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"117\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"2\" data-formid=\"1908\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"2\" data-formid=\"1908\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" style=\"display:none;\"><div id=\"wpforms-1908-field_71-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"71\"><h3 id=\"wpforms-1908-field_71\" name=\"wpforms[fields][71]\">Step 3: Summary of Complaint<\/h3><\/div><div id=\"wpforms-1908-field_72-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_72\">In the case of a motor vehicle claim, describe the accident and indicate which of the following is the reason for the complaint:<\/label><ul id=\"wpforms-1908-field_72\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_72_1\" name=\"wpforms[fields][72][]\" value=\"Inadequate Settlement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_72_1\">Inadequate Settlement<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_72_2\" name=\"wpforms[fields][72][]\" value=\"Undue Delay\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_72_2\">Undue Delay<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_72_3\" name=\"wpforms[fields][72][]\" value=\"Denial of Claim\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_72_3\">Denial of Claim<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_72_4\" name=\"wpforms[fields][72][]\" value=\" Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_72_4\"> Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-1908-field_73-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"73\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_73\">Please specify:<\/label><input type=\"text\" id=\"wpforms-1908-field_73\" class=\"wpforms-field-medium\" name=\"wpforms[fields][73]\" ><\/div><div id=\"wpforms-1908-field_74-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"74\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-1908-field_74\">Summary of Complaint (Paragraph)<\/label><textarea id=\"wpforms-1908-field_74\" class=\"wpforms-field-medium\" name=\"wpforms[fields][74]\" placeholder=\"Please write your description here\" ><\/textarea><\/div><div id=\"wpforms-1908-field_75-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_75\">How would you like the Bank\/Insurance Company to resolve this complaint?<\/label><textarea id=\"wpforms-1908-field_75\" class=\"wpforms-field-medium\" name=\"wpforms[fields][75]\" placeholder=\"Please write your suggestion here\" ><\/textarea><\/div><div id=\"wpforms-1908-field_118-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"118\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"3\" data-formid=\"1908\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"3\" data-formid=\"1908\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" style=\"display:none;\"><div id=\"wpforms-1908-field_121-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"121\"><h3 id=\"wpforms-1908-field_121\" name=\"wpforms[fields][121]\">Step 4: Agreements<\/h3><\/div><div id=\"wpforms-1908-field_77-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"77\"><h3 id=\"wpforms-1908-field_77\" name=\"wpforms[fields][77]\">Complainant\u2019s Authority:<\/h3><div class=\"wpforms-field-description\"><br>\r\nThe FSO will need to access personal details, including financial information about me, in order to deal with my complaint effectively. The FSO will handle such information in the strictest confidence unless compelled by law to disclose this information.\r\n<br>\r\n<br>\r\n2. The FSO, Central Bank of Trinidad and Tobago and other organizations and official bodies, including the Bank\/Insurance Company I am complaining about, have the authority to exchange information about this complaint.\r\n<br>\r\n<br>\r\n3. My case may be published for educational purposes or be reflected in the FSO\u2019s statistics but the identity of the parties would not be revealed.\r\n<br>\r\n<br>\r\n4. Complaints are handled in a different manner from a Court of law and the FSO would not usually require parties to attend hearings in person. Instead, disputes are resolved by correspondence, telephone or other means of communication.\r\n<br>\r\n<br>\r\n5. The FSO may dismiss my complaint if I fail to provide information when requested, or, if I fail to reply to letters from the Office within a reasonable time. My complaint may also be dismissed if I am upsetting, abusive or insulting when communicating with the Office. The FSO has the sole right to determine whether I have been upsetting, abusive or insulting.\r\n<br>\r\n<br>\r\n6. If at any time I am not satisfied with the process or the outcome, I am free to take the matter to Court or elsewhere. In such a case, I would inform the FSO immediately, in writing, and the FSO will close its files on my complaint.\r\n<br>\r\n<br>\r\n<\/div><\/div><div id=\"wpforms-1908-field_85-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"85\"><h3 id=\"wpforms-1908-field_85\" name=\"wpforms[fields][85]\">Complainant\u2019s Agreement<\/h3><div class=\"wpforms-field-description\">By signing this Complaint Form, I agree to:\r\n<br>\r\n<br>\r\n1. Give my consent to the Bank\/Insurance Company against which I am complaining, to release any necessary information to the FSO which is related to my complaint.\r\n<br>\r\n<br>\r\n2. Give my consent to the FSO and the Bank\/Insurance Company to exchange any information relevant to my complaint.\r\n<br>\r\n<br>\r\n3. Keep all discussions between the Bank\/Insurance Company, the FSO and I confidential. Should my complaint be the subject of a Court matter or any other dispute-resolving process, neither my representative nor I, will subpoena any documents in my file or the Ombudsman or any member of her staff. Neither my representative nor I will order that any of these documents be discovered in terms of any rules of Court.<\/div><\/div><div id=\"wpforms-1908-field_88-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"88\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_88\">Please tick the box(es) for the documents you have included:<\/label><ul id=\"wpforms-1908-field_88\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_1\" name=\"wpforms[fields][88][]\" value=\"Copy of Proof of Ownership of Property\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_1\">Copy of Proof of Ownership of Property<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_2\" name=\"wpforms[fields][88][]\" value=\"Copy of Insurance Certificate\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_2\">Copy of Insurance Certificate<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_3\" name=\"wpforms[fields][88][]\" value=\"Copy of Certified Copy of Ownership\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_3\">Copy of Certified Copy of Ownership<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_4\" name=\"wpforms[fields][88][]\" value=\"Copy of Bill(s) for Repairs\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_4\">Copy of Bill(s) for Repairs<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_5\" name=\"wpforms[fields][88][]\" value=\"Copy of Police Report\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_5\">Copy of Police Report<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_6\" name=\"wpforms[fields][88][]\" value=\"Pictures\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_6\">Pictures<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_7\" name=\"wpforms[fields][88][]\" value=\"Copy of Bank Statement(s)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_7\">Copy of Bank Statement(s)<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_9\" name=\"wpforms[fields][88][]\" value=\"Copy of Estimate\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_9\">Copy of Estimate<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_10\" name=\"wpforms[fields][88][]\" value=\"Copy of Loan Agreement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_10\">Copy of Loan Agreement<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_11\" name=\"wpforms[fields][88][]\" value=\"Copy of Policy Contract\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_11\">Copy of Policy Contract<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_12\" name=\"wpforms[fields][88][]\" value=\"Witness Statement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_12\">Witness Statement<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_13\" name=\"wpforms[fields][88][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_13\">Other<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1908-field_88_8\" name=\"wpforms[fields][88][]\" value=\"Copy of the Bank\u2019s\/ Insurance Company\u2019s final decision letter\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1908-field_88_8\">Copy of the Bank\u2019s\/ Insurance Company\u2019s final decision letter<\/label><\/li><\/ul><\/div><div id=\"wpforms-1908-field_125-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"125\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_125\">If other, please specify:<\/label><input type=\"text\" id=\"wpforms-1908-field_125\" class=\"wpforms-field-medium\" name=\"wpforms[fields][125]\" ><\/div><div id=\"wpforms-1908-field_119-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"119\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"4\" data-formid=\"1908\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"4\" data-formid=\"1908\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5 last \" style=\"display:none;\"><div id=\"wpforms-1908-field_89-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"89\"><h3 id=\"wpforms-1908-field_89\" name=\"wpforms[fields][89]\">Step 5: Supporting Documents<\/h3><\/div><div id=\"wpforms-1908-field_76-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"76\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_76\">If you are making a claim for monetary compensation, provide a detailed list of the items comprising the amount of the claim. For example, parts ($...........) and\/or labour ($...........). Please include supporting evidence.<\/label><textarea id=\"wpforms-1908-field_76\" class=\"wpforms-field-medium\" name=\"wpforms[fields][76]\" placeholder=\"Please write your list of items here\" ><\/textarea><\/div><div id=\"wpforms-1908-field_124-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"124\"><label class=\"wpforms-field-label\" for=\"wpforms-1908-field_124\">File Upload<\/label><input type=\"file\" id=\"wpforms-1908-field_124\" data-rule-extension=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,xwav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\" data-rule-maxsize=\"52428800\" name=\"wpforms_1908_124\" ><\/div><div id=\"wpforms-1908-field_116-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"116\"><div class=\"wpforms-clear wpforms-pagebreak-split\"><button class=\"wpforms-page-button wpforms-page-prev\" data-action=\"prev\" data-page=\"5\" data-formid=\"1908\">Previous<\/button><\/div><\/div><\/div><\/div><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-field_hp\" class=\"wpforms-field-label\">Message<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-field_hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-recaptcha-container\" style=\"display:none;\"><div class=\"g-recaptcha\" data-sitekey=\"6LfzZn8UAAAAAIAGD3wqleq6n0-t1J3cZKo9EDYM\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" required><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"1908\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"17\"><button type=\"submit\" name=\"wpforms[submit]\" class=\"wpforms-submit \" id=\"wpforms-submit-1908\" value=\"wpforms-submit\" data-alt-text=\"Sending...\">Submit Complaint<\/button><\/div><\/form><\/div>[\/vc_column][vc_column width=&#8221;1\/6&#8243;][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":17,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template-page-full-width.php","meta":{"footnotes":""},"class_list":["post-1823","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/ofso.org.tt\/index.php\/wp-json\/wp\/v2\/pages\/1823","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ofso.org.tt\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/ofso.org.tt\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/ofso.org.tt\/index.php\/wp-json\/wp\/v2\/users\/17"}],"replies":[{"embeddable":true,"href":"https:\/\/ofso.org.tt\/index.php\/wp-json\/wp\/v2\/comments?post=1823"}],"version-history":[{"count":0,"href":"https:\/\/ofso.org.tt\/index.php\/wp-json\/wp\/v2\/pages\/1823\/revisions"}],"wp:attachment":[{"href":"https:\/\/ofso.org.tt\/index.php\/wp-json\/wp\/v2\/media?parent=1823"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}