Subject: Complaint against [insurer name], policy no. [____], by [your name]

To: [office email from the table above]

Sir/Madam,

Please find attached my complaint under Rule 14 of the Insurance Ombudsman Rules, 2017 against [insurer name], branch [name, city].

My address is [full address with PIN code] ([state/district]), which I understand falls under your jurisdiction. The insurer's branch concerned is in [city, state]. If this matter belongs to a different Ombudsman office, please tell me which one and I will re-send it.

I made a written complaint to the insurer on [date]. The insurer [rejected it on [date] / has not replied for more than one month / replied on [date] and I am not satisfied]. Copies are attached.

Attachments:
1. Complaint letter (signed)
2. My written complaint to the insurer and proof of sending
3. Insurer's reply or rejection letter, if any
4. Policy copy
5. KYC particulars
6. Claim documents

Mobile: [number]
[Name]