Consumer Complaint Form

Authorization – Disclosure of Information – Important Notice

The following is an authorization that you must sign to allow the Insurance Council of Manitoba (the “Council”) to collect and use your personal information and, if necessary, to reasonably disclose it to particular persons and entities. Please read it over carefully. If you have any questions about this authorization, please email contactus@icm.mb.ca.

The information on the complaint form is being collected by the Council under the authority of The Insurance Act of Manitoba. By completing this form, you are consenting to the Council and its employees using and disclosing the personal information contained in the complaint form and any additional information that you supply, generally:

For the purpose of its investigating function
For the purpose of administering The Insurance Act of Manitoba and Regulations made thereunder
For the purposes of enforcing The Insurance Act and Regulations made thereunder, and the administration and enforcement of any other applicable laws

In particular you are also consenting to the reasonable and necessary disclosure of the personal information you have provided, and may provide, to the following persons or entities:

The insurance company and/or the agent or adjuster with whom you have conducted business and about whom you make complaint Insurance agents, brokers or adjusters involved in aspects of your complaint Government ministries, agencies, boards or commissions with functions to investigate or administer or enforce applicable laws
Self-regulatory agencies or associations with recognized authority to investigate or administer or enforce applicable laws


I hereby authorize the Council to collect, use and make reasonable and necessary disclosure of the information I have submitted and any additional information I may submit about my complaint. I further understand that information may also be obtained from an insurance company, or any other source the Council deems appropriate and necessary in order to investigate this complaint.