CISAS Complain Now Online Form

Section 1

This application form is for customers to bring a claim against a communications provider that subscribes to CISAS. The application form will ask you for the details needed to understand what you would like the company to do and decide your dispute. Applications can only be accepted after you have given the communications provider a period of at least 8 weeks in which to address your complaint, or at any time after the provider communicates to you that they have reached deadlock.

What do I need to do?:
- Read the Rules and the Guidance for Customers fact sheet. If you are unsure of how to answer a question please contact CISAS for guidance.
- Fill in the application form giving as much information as you can
- It may take you some time to go through the application form and get all your facts together but having all the information will help CISAS assess your case fairly
- You must provide evidence to prove your claim.

1. About you
Full name*
Organisation (if applicable)
Address*
Address 1 Address 2 Town/City Post code
Email address*
Please note that we will correspond with you about your complaint by email.
Telephone number
Representative
Do you need a representative to complete the form on your behalf? Please confirm below
- Yes (if Yes please proceed to 2. Representative)
- No (if No, go to 3. Your Dispute)

2. Representative
You may elect to have a representative act for you (at your own cost). If you choose to do this, provide their full contact details below.
Full name
Organisation (if applicable)
Email address
Please note that we will correspond with you about your complaint by email.
Telephone number

3. Your Dispute
Please provide some information on the service(s) that your dispute relates to.
Which provider does your dispute relate to?*
Does your dispute relate to a residential or business account?
What service does your dispute relate to?
Which of the options best describes the nature of your dispute?

4. About Your Account
Account holder name
Mobile/landline number(s)
Account number(s)
Have you raised your complaint with the communications provider directly?
- Yes
- No
We can only process complaints that have first been raised with your communications provider.

Has 8 weeks elapsed since you made your complaint?
- Yes
- No
We can only process claims that have been first submitted to the communications provider and 8 weeks have elapsed since you made the complaint. However, if you have received a final response or deadlock and 8 weeks haven’t lapsed, we will be able to assist.
On what date did you first complain to the provider?
If you are a business customer, how many employees are in your business?

5. ADR Referral / Deadlock Letter
The communications provider may have sent you a letter or email headed ‘written notice’, ‘final response’ or ‘deadlock letter’. A deadlock letter is a communication from the provider that tells you that you have reached the end of their complaints procedure and that the dispute cannot be resolved. An ADR referral letter is communication advising that your matter has been ongoing for a period of 8 weeks and a resolution has not yet been reached.
Have you received an ADR referral letter?
- Yes
- No
What is the date on the ADR referral letter? (if received)?
What is the reference number on the ADR referral letter?
Did the ADR referral letter mention CISAS?
- Yes
- No

6. How did you find out about CISAS?
How did you reach us?
Select one option from the list below
- CISAS Website
- Online forum
- Social media
- Ofcom

7. Your Complaint
Please provide the details of the issues you have experienced and ensure that you: - Provide as much relevant detail as you can; - Ensure you provide evidence, written or otherwise, that supports your claim
7.1. The Contract
Please tell us what goods and services, provided or not provided by the provider this dispute relates to (e.g broadband, mobile phone, VoIP):
7.2. Issues in Dispute
Tell us in more detail what exactly you are in dispute with the provider about. Please continue on a separate sheet if required.
7.3 Associated Files
Please upload any other documents here you think are relevant to your submission,
Drop files here or

Max. file size: 5 MB.

Evidence

In order to prove your claim, you must submit evidence that supports your position. Where possible your evidence should be submitted in chronological order. You may wish to provide any of the following evidence:
- A copy of the agreement or contract you had with the provider.
- Invoices and/or receipts for the cost of the product and/or service.
- Letters and/or email communications with the provider
- Photographs.
- Price schedules.
- Receipts for all expenses you wish to claim for.
- Recordings (Audio).
- Screenshots of the provider’s website.
- Screenshots of other websites (Consumer forums etc.
- Terms & Conditions of the provider.
- Video evidence.
As part of the adjudication process, a copy of your application and all submitted evidence will be sent to the communications provider concerned in order for them to respond to the claims you have made and to submit their own evidence in defence. A copy of that evidence will be sent to you.
8. What would you like the company to do?
Please provide details of the services, compensation or other actions that you would like the adjudicator to direct the provider to provide or undertake.
8.1. Give you a product or service?
- Yes
- No
Please provide details of the product and / or service you are seeking:
8.2 Take some action
- Yes
- No
What action would you like to be taken?
8.3. Give an apology
- Yes
- No
Please provide details of the apology you are seeking:
8.4. Pay you compensation
- Yes
- No
Item & Amount Claimed (£)*
Please describe in this box the item and the amount claimed (in £)
You must specify the total amount claimed in this section if you are asking the adjudicator to direct the provider to pay you in compensation.
The maximum amount you can claim is £10,000. You must provide evidence to justify the amount claimed and you cannot change the amount at a later date. Please note that the adjudicator may award less than the company has previously offered.

Item	Amount Claimed
Describe item here	Insert figure here (£)

9. Customer’s declaration*
Please read these declarations and tick all three boxes to confirm you understand them before signing this form.
- I have read and understood the CISAS Rules and the guidance notes provided with the application form.
- I have not previously referred this dispute to a court of law.
- I have tried to resolve this matter through the provider’s own complaints procedure.
Full Name
Your Signature
Date

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CISAS Complain Now Online Form

Step 1 of 11 - Section 1

Section 1

What do I need to do?:

1. About you

2. Representative

3. Your Dispute

4. About Your Account

5. ADR Referral / Deadlock Letter

6. How did you find out about CISAS?

7. Your Complaint

Evidence

8. What would you like the company to do?