Consumer Complaint

Required Fields are marked with an asterisk(*).

Date: 12-15-2018

Please Note: Entry of accented characters such as ¿, é, á and ñ are not supported in this form.

Complainant's Information:

Are you the Insured? YesNo

What is your relationship to the insured?

Are you currently represented by an attorney for this matter? YesNo

*First Name:

Middle Name:

*Last Name:

*Address Line 1:

Address Line 2:

Address Line 3:

Address Line 4:

Address Line 5:

Address Line 6:

*City:

*State:

*Zip:

County:

*Country:

International Zip:

Email Address:

Please Reenter Email Address for Verification:

*Phone Number: Extension:

Alternate Phone Number: Extension:

How do you prefer to be contacted?:

Insured Information (If different than above):

First Name:

Middle Name:

Last Name:

Other Parties involved in this problem:

First Name:

Last Name:

Description:

First Name:

Last Name:

Description:

First Name:

Last Name:

Description:

First Name:

Last Name:

Description:

Insurance information:

*Who is the Complaint Against? Provide the name of one or more of the parties you are complaining against.

a. Name of Insurance Company:

b. Name of Insurance Agency:

c. Name of Insurance Agent, Adjuster, Appraiser:

First Name:

Last Name:

In what state did you purchase this plan? State:

Policy Number:

Certificate Number:

Claim Number:

Date of Loss/Service:

Date of Cancellation:

Insured Age Group:

Amount Disputed:
(Do not enter a dollar sign or comma)

*Type of Insurance	*Reason for Complaint (Check at least one or use the Ctrl key to make multiple selections)
Other Desc:	Other Desc:

*Details of Complaint:

Maximum Complaint Detail Limit- 4000 Characters. Characters Left

What do you consider to be a fair resolution?

Maximum Fair Resolution Limit- 4000 Characters. Characters Left

Note: After final submission of this form you will be provided with an opportunity to attach supporting documents.
Will you be mailing or faxing additional supporting information? Yes No

If mailing supporting documents, please include a copy of this form and mail to:

Missouri Department of Insurance
Attn: Consumer Affairs
P O Box 690
Jefferson City, MO 65101-0690

or FAX supporting documents along with a copy of this form to: (573) 526-4898

You will have the opportunity to change your complaint before it is submitted.

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