Consumer Complaint Form

Required fields are marked with an asterisk. *

Date: 10-18-2025

Please Note: Entry of accented characters such as ñ, ¿, and ¡ are not supported in this form. OCI assists consumers with their insurance problems. Please complete this form as thoroughly as you can. Your complaint will be sent to the company and/or agent for a response. The company and/or agent may contact you directly regarding your complaint. We will review the company and/or agent response and notify you of our determination.

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

After you submit this form, you can also submit supporting documents later by one of the following methods. You will receive confirmation with your Case Tracking #. Be sure to include your Case Tracking # with your submission. Online: https://ociaccess.oci.wi.gov/complaints/public/editComplaint

Email: ocicomplaints@wisconsin.gov

Fax: (608) 266-8115

Mail:

Wisconsin Office of the Commissioner of Insurance
101 East Wilson Street
P. O. Box 7873
Madison, WI 53703-7873

Email Confirmation

*Do you wish to receive email confirmation?

Yes

Authorization

The information I have given is true and accurate to the best of my knowledge. This information may be forwarded to the insurance company, if necessary, for the investigation of this matter. The Wisconsin Office of the Commissioner of Insurance has my permission to exchange any information I provide to the Wisconsin Office of the Commissioner of Insurance with my insurer(s), agent/broker and their contractors if relevant, and any representative or other person I have named in this complaint.

Authorization

Yes