SUPERINTENDENCIA DE SEGUROS Y REASEGUROS DE PANAMÁ
FORMULARIO DE QUEJA
Panamá , ____de __________de 20____
Señ or
Superintendente de Seguros y Reaseguros E. S. D.
Quien suscribe,____________________________________________________ , portador(a) de la Cédula de
identidad personal número ________________________, por este medio presento formal Queja en
contra de Aseguradora________________________________________________________________ N° de
Reclamo______________________________ N° de Póliza _____________________________________
Tipo de consumidor: Asegurado Afectado Beneficiario
HECHOS.
(Por favor describa los hechos en letra imprenta legible.)
PRIMERO:
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SEGUNDO:
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TERCERO:
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CUARTO:
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QUINTO:
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SEXTO:
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SÉ PTIMO:
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OCTAVO:
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NOVENO:
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PRUEBAS
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SOLICITUD
(No se incluye lucro cesante, perjuicios, costas y honorarios profesionales)
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Firma :____________________________________________ Cédula:___________________________________________
Teléfono: __________________________________ Teléfono móvil: ________________________________________
Dirección Completa: __________________________________________________________________________________________
Correo electrónico: __________________________________________________________________________________
