Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 06-12-2021


Complainant's Information



Insured's Information(If different than above)

Other Parties involved in this problem

Insurance Information

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



Details and Supporting Documents

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Note: After final submission of this form you will be provided with an opportunity to attach supporting documents
If mailing supporting documents, please include a copy of this form and mail to:
Insurance Consumer Services Section
Arizona Department of Insurance and Financial Institutions
100 N. 15th Ave. Ste. 261
Phoenix, AZ 85007-2630
or EMAIL supporting document along with a copy of this form to insurance.consumers@difi.az.gov
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The Arizona Department of Insurance and Financial Institutions provides equal access to communications for people with disabilities. Individuals requiring accommodation with a disability should call the Department`s ADA Coordinator at 602-364-3100.

Email Confirmation

Authorization

I declare, under penalty of perjury, that the information contained in this complaint, including all documents submitted with or in support of this complaint, are true, accurate, and based upon my personal knowledge. I understand that this complaint and/or certain information and documents related to this complaint may become a matter of public record, pursuant to state or federal law.