Consumer Complaint Form

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

Are you the insured?

Yes

What is your relationship to the insured?

Are you currently represented by an attorney for this matter?

Yes

*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

Reenter Email:

*Phone Number:

EXT:

Alternate Phone Number:

EXT:

How do you prefer to be contacted? :

Insured's Information(If different than above)

First Name:

Middle Name:

Last Name:

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 Agent, Adjuster, Appraiser

First Name:

Last Name:

In what state did you purchase this plan?

How was the Policy Purchased?:

Are you presently in litigation?

Yes

Have you litigated your claim?

Yes

If you answered "Yes" what was the court's decision?:

4000 characters remaining.

Policy Number:

Certificate Number:

Claim Number:

Date of Loss/Service:

Date of Purchase:

Date Of Cancellation:

Insured Age Group:

Amount in Dispute:

*Type of Insurance:

*Reason For Complaint:

Other Desc:

Details and Supporting Documents

*Details Of Complaint:

4000 characters remaining.

*What do you consider to be a fair resolution?:

4000 characters remaining.

Note: After final submission of this form you will be provided with an opportunity to attach supporting documents

Yes

Will you be mailing or faxing additional supporting information?

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

*Do you wish to receive email confirmation?

Yes

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