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General Information for Filing a Consumer Complaint (PDF)

Receiving your submission electronically allows us to begin the information-gathering process. Fields marked with an asterisk

1. Name     * First Name     * Last Name 2. Address Information * Line 1 Line 2 * City * State * Zip Code 3. Contact Information * Daytime Phone (xxxxxxxxxx format) * E-Mail   4. * Type of Insurance (select only one) Select One Auto Workers' Compensation Homeowner's Commercial Life Health Disability Medicare Supplement Other(Please specify below)   <5.* My complaint is against (select all that apply)  Company Adjuster  Agent Other (please describe below)   6. * The involved insurance company is associated with (select one) Select One My policy Someone else's policy   7. Information on your policy: Company Policy/ID Number Agent Name Agent Address     8. Information on other party's policy:     (If applicable) Insured's Name Company Policy/ID Number Adjuster's Name Adjuster's Address   9. Are you represented by an attorney? Select One Yes No     10. In the area below, briefly describe your complaint and enter any additional information. (Maximum of 4500 characters) You have 5000 characters remaining for your description...     11. When you've entered the required information, press the Submit Complaint button below so your complaint can be processed. Please DO NOT hit the Submit Complaint button more than once.