CONTROL DE ENTRADA EN LA OFICINA DE RECEPCIΣN

 

FECHA:

 

FIRMA DEL RECEPTOR:
 

CENTRO TECNICO DE SEGUROS, CORREDURIA DE SEGUROS, S.A.

RUIZ DE ALDA, 1 BJ 3

28342 VALDEMORO, MADRID

Tel.  918950917

Fax. 918951162

 

 

 

HOJA DE RECLAMACIΣN

(COMPLAINT FORM)

 

 

1.                    LUGAR DEL HECHO

               (Place of occurrence)

 

EN:..............………………….................................................................... PROVINCIA:................................................. FECHA:..................................

(Town)                                                                                                      (Province)                                                (Date)

 

 

2.                    IDENTIFICACIΣN DEL RECLAMANTE 

                (Details of Complainant)

 

 

1er APELLIDO:............................................................................................................  2Ί APELLIDO:.......................................................................... 

(Surname)

 

NOMBRE: ......…....................................................... D.N.I. / C.I.F./ NΊ DE REGISTRO PΪBLICO : ……................................................

                                                                                                                                              

(Name)                                                                                  (Passport Number/Register Number/ Fiscal Number)

 

DOMICILIO C/: ……………..............................................……….............................C.P:……….......  MUNICIPIO:……..………………………………….          

(Address Street)                                                                                                     (Postal code)     (Town)

 

PROVINCIA:...............................................................NACIONALIDAD................................................................TELΙFONO......................................

(Province)                                                                   (Nationality)                                                                        (Telephone)

 

 

3.             IDENTIFICACIΣN DEL RECLAMADO

                (Details of Natural Person or company under complaint)

 

 

NOMBRE O RAZΣN SOCIAL: ....................................................................................................................... C.I.F O D.N.I:.........................................

(Name Of Company)                                                                                                                                       (Fiscal No or Passport No)           

 

DOMICILIO:………………………………………………………………………..…………………………………………..………… C.P:……................….....

(Address St.)                                                                                                                                                       (Postal code)      

 

MUNICIPIO: ………………………………………………………….......…PROVINCIA:......................................... TELΙFONO:......................................

(Town)                                                                                                   (Province)                                              (Telephone Number)

 

 

4.           HECHOS  RECLAMADOS: (Details of Complaint)

 

…………………………………………………………………………………………………………………………………………..............................................

 

……………………………………………………………………………………………………………………………………………...........................................

 

……………………………………………………………………………………………………………………………………………...........................................

 

……………………………………………………………………………………………………………………………………………...........................................

 

 

DOCUMENTOS QUE SE ACOMPAΡAN: .....................................................................................................................................................................

(Documents Included)

.........................................................................................................................................................................................................................................

 

.........................................................................................................................................................................................................................................

 

 

El reclamante reconoce no tener conocimiento de que la materia objeto de la queja o reclamaciσn estα siendo sustanciada a travιs de un procedimiento administrativo, arbitral o judicial.

 

 

FIRMA DEL RECLAMANTE:                                                                             FIRMA DEL RECLAMADO:

(Signature of Complainant)                                                                              (Siganture of Person or Company

                                                                                                                             under complaint)

 

 

...............................................                                                                             ..................................................

 

 

 

En ..............................a.........de...........................de ......................