Form for the request for mediation

First name and surname*

Street and house number*

Postcode and city*

Your e-mail address*

Information about provider (insurance or pension company from the list):*

The facts that generate the dispute / alleged breaches – summary of the request:*

Evidence substantiating the request (attachments):*

The complaint is pending under another dispute resolution body, an
administrative body or by a court:*


Yes No 

The complaint is being considered by another dispute resolution body, an
administrative body or by a court:*


Yes No 

The final answer of the provider in an internal complaints handling procedure is dated,
or your complaint has been lodged within an internal complaints handling procedure on date:*

A proposal on the appointment of a mediator from the list of mediators, or a declaration that a
mediator may be appointed by the MC Secretary:*

The fields with * are mandatory.


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