Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 04-23-2021

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

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.
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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:
North Dakota Department of Insurance
Attn: Consumer Assistance Division
600 E Boulevard Ave
Bismarck, ND 58505
or FAX supporting documents along with a copy of this form to: (701)328-9610
or EMAIL supporting document along with a copy of this form to: insurance@nd.gov

Email Confirmation

Authorization

If complaint involves a health or an injury claim, please complete the following: I authorize the above listed insurance company to release medical information in their possession to the North Dakota Insurance Department pertaining to ___________ , who is insured under Policy No.________ . I expressly release the above named insurance company from any and all liability in connection with the release of this medical information. 45 CFR 164.512 allows the release of the information to the Department. I understand that the release of the above information is for investigative purposes only. I further understand that the facts relating to this complaint, except for personal non-public financial information, will become a matter of public record, and I agree to the release of such information if requested by a member of the public.
*
Agree