Customer Feedback Form

Customer Feedback Form
Thank you for taking the time to share your feedback with La Capitale Insurance and Financial Services.
Your comments are important, because we want to make your experience with us the best!
Please tell us which service, location or department you dealt with (e.g. Head or branch office, agent or broker).
Please tell us the date and time of your visit or interaction with us.
Date:
Time:
a.m
p.m.
What products or services were you interested in?
How satisfied were you with the customer service you received from us?
Very satisfied
Satisfied
Dissatisfied
Very dissatisfied
Was our customer service provided to you in an accessible manner?
Yes
No
Comments:
What could we do to make it easier for you to access our products and services?
If you would like us to contact you to discuss your feedback, please provide your contact information below.
Name:
Email:
Day phone number:
Best time to contact you:
Evening phone number:
a.m
p.m.
Address:
Please return the completed form by email, fax or regular mail to:
La Capitale Insurance and Financial Services inc.
7150 Derrycrest Drive, Mississauga, ON L5W 0E5
Email: [email protected]
Fax: 905 795-2313
La Capitale Insurance and Financial Services is collecting the personal information you provide on this form in order to respond to your feedback.
If you have questions about the collection, use and disclosure of your personal information by La Capitale Insurance and Financial Services, please
contact the Accessibility Committee Department at 1 888 816-9874 or [email protected]
Please note this form is reserved for queries related to the accessibility of the products and services offered by La Capitale Insurance and Financial
Services to persons with disabilities.
For Company use only
Date of follow-up:
Name of person following up:
Results:
14-131
Action taken: