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Consumer Complaint |
Required Fields are marked with an asterisk(*).
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Date: 2-22-2019 |
Please Note: Entry of accented characters such as ¿, é, á and ñ are not supported in this form.
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Complainant's Information:
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Are you the Insured?
YesNo
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What is your relationship to the insured?
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Are you currently represented by an attorney for this matter?
YesNo
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*First Name:
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Middle Name:
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*Last Name:
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*Address Line 1: |
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Address Line 2: |
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Address Line 3: |
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Address Line 4: |
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Address Line 5: |
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Address Line 6: |
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*City:
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*State:
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*Zip:
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County:
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*Country:
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International Zip:
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Email Address: |
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Please Reenter Email Address for Verification: |
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*Phone Number:
Extension:
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Alternate Phone Number:
Extension:
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How do you prefer to be contacted?:
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Insured Information (If different than above):
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First Name:
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Middle Name:
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Last Name:
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Other Parties involved in this problem:
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First Name:
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Last Name:
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Description:
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First Name:
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Last Name:
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Description:
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First Name:
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Last Name:
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Description:
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First Name:
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Last Name:
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Description:
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Insurance information:
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*Who is the Complaint Against? Provide the name of one or more of the parties you are complaining against.
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a. Name of Insurance Company:
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b. Name of Insurance Agency:
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c. Name of Insurance Agent, Adjuster, Appraiser:
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First Name:
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Last Name:
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In what state did you purchase this plan? State:
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Policy Number:
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Certificate Number:
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Claim Number:
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Date of Loss/Service:
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Date of Cancellation:
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Insured Age Group:
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Amount Disputed:
(Do not enter a dollar sign or comma)
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*Details of Complaint:
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Maximum Complaint Detail Limit- 4000 Characters. Characters Left
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What do you consider to be a fair resolution?
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Maximum Fair Resolution Limit- 4000 Characters. Characters Left
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If mailing supporting documents, please include a copy of this form and mail to: