| BETWEEN: |
| Appellant |
| And |
| Respondent |
| NOTICE OF APPEAL |
| Take notice that (1) |
| , an insurer, insurance agent, insurance broker, insurance |
| salesperson or a person aggrieved by the decision of the Authority, |
| (2) |
| being dissatisfied with the decision of the Authority dated day |
| of 20 of which I received notice |
| on the day of 20 |
| That (3) |
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| hereby appeal(s) to the Insurance Appeals Tribunal for the reasons set out in paragraph 5 below and will at the hearing of the appeal seek a decision to the Tribunal that |
| (4) |
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| REASONS FOR APPEAL |
| And further take notice that the reasons for which I desire to appeal against the said decision are as follows (5) |
| (a) |
| (b) |
| (c) etc. |
| All notices or other documents relating to this appeal may be sent to me at (6) |
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| Dated this day of 20 |
| To: The Secretary |
| The Insurance Appeals Tribunal |
| Note: |
| (1) Name of appellant |
| (2) Office/occupation |
| (3) Insert substance of the decision appealed against |
| (4) State order sought from the Tribunal |
| (5) Reasons for appeal |
| (6) Address |