eFile for Compensation Application for CompensationFILL OUT YOUR FORM IN 10 STEPS Please enable JavaScript in your browser to complete this form. - Step 1 of 10If your business has suffered due to anti-competitive practices, you can use this form to seek redress. This eFile form provides a platform to lodge a compensation claim, offering a secure and organized method for presenting your case and attaching relevant evidence.I agree to ERCA's Privacy Policy *YesBy checking this box, I confirm that I fully agree with the ERCA's Privacy PolicyNextINSTRUCTIONSThis Form must be completed to the best of your ability and submitted to the ERCA Registry. Please attach any documents or relevant information to support your complaint. The information provided in this Form is confidential to the extent possible to enable ERCA investigate your complaint. However, ERCA may disclose this information where necessary to assist its investigation. ERCA will contact the Complainant where it considers that it is necessary to disclose such information. However, for the avoidance of doubt, you have the right to identify which information you consider confidential by submitting a request for confidentiality together with this complaint.1. DETAILS OF APPLICANTFull Name of Applicant or Authorised Representative *Name and address of contact person *WebsitePhoneEmail *Description of Industry/sector * Visual Text If this application is being submitted jointly with other natural and/or legal person(s), please indicate and provide full details of the other applicants * Visual Text Legal Mandate Click or drag files to this area to upload. You can upload up to 99 files. Where this Form is completed by an Authorised Representative, please state the nature of your relationship with the beneficiary and whether you have the legal mandate to represent the beneficiary. (attach copy of legal mandate if applicable)PreviousNext2. DETAILS OF THE RESPONDENTFull Name of Respondent(s) *Full Name of Enterprise *Address/LocationPhoneEmailOther Contact Details of the RespondentWebsiteNature and scope of business * Visual Text PreviousNext3. DETAILS OF THE ALLEGED INFRINGEMENT Provide details of the alleged infringement, which was investigated by ERCA. Indicate the goods or services affected by the infringements and explain, where necessary, the commercial relationships concerning these products or services * Visual Text PreviousNext4. ERCA DECISION Provide any available details on ERCA’s decision in relation to the anti-competitive activity(s) including sanctions imposed by ERCA Visual Text PreviousNext5. IMPACT OF INFRINGEMENTPlease explain how and to what extent the infringement has affected your competitive position / the competitive position of the person/enterprise you represent. * Visual Text PreviousNext6. EVIDENCE OF THE DAMAGE SUFFERED Explain and provide evidence of the damage you have suffered as a result of anti-competitive behaviour. Please provide tangible evidence(s) Visual Text Evidence of damage suffered Click or drag files to this area to upload. You can upload up to 99 files. PreviousNext7. PROCEEDINGS BEFORE REGIONAL/NATIONAL COMPETITION AUTHORITIES OR COURTSPlease indicate whether you have approached any other Regional/National Competition Authority in relation to the same or closely related alleged infringement and/or whether you have brought legal proceedings before any Regional/National court. If so, provide details about the authority contacted and your submissions to such authority or court * Visual Text PreviousNext8. SWORN DECLARATIONI declare that the information in this Form and all supporting documents I have attached are accurate and provided to ERCA in good faith.Print Name *Position *Date *PreviousNextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.PreviousConfirm and Submit ERCA Complaint Management System Introducing ERCA Statistical System
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