Good Day (The Name Of Your Boss)
I would like to bring the following incident (what and when and where did it happen) to your attention.
I am distraught with the actions of (the party involved). I tried (how did you try to remedy the situation), but my attempts to resolve the case were unsuccessful.
I am now turning to you for the necessary assistance with this matter. I hope that you can come up with a solution.
Thank you in advance, and please let me know if you need any clarification.