Claim Book

Identification of the complaining consumer

First name * First Surname * Second Surname * Document type * Document number * Mobile phone * Department * Province * District *

Address * Reference

Email *

Detail of the claim and order of the consumer

(1) Claim: Disagreement related to products and/or services.
(2) Complaint: Disagreement not related to products and/or services; or, discomfort or dissatisfaction with public service.

Tipo de reclamo * Type of consumption * Order No. * Provider * Claimed amount (S/.) * Claim/Complaint date *

Description of the product or service *

Purchase date Consumption date Expiration date

Detail of the Claim / Complaint, as indicated by the customer *

I declare that I own the service and accept the content of this form by declaring the veracity of the facts described. Subscribed under sworn declaration of the veracity of the facts described. I accept the terms and conditions

* The filing of the claim does not exclude recourse to other means of dispute resolution nor is it a prerequisite for filing a complaint with Indecopi.
* The provider must respond to the claim within a period not exceeding thirty (30) calendar days, and may extend the period up to thirty more days.
* By signing this document, the customer authorizes being contacted after the processing of the claim to evaluate the quality and satisfaction of the claims attention process.

Identification of the complaining consumer

Detail of the claim and order of the consumer

COMPANY