Consumer Complaint

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Date: 09-29-2020

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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:
Iowa Insurance Division
1963 Bell Avenue
Suite Suite 100
Des Moines, IA 50315
or FAX supporting documents along with a copy of this form to: (515) 281-3059

Email Confirmation

Authorization

By submitting this complaint, you verify that your statements are true, and without otherwise waiving the confidentiality protection of Iowa Code Section 505.8, you are authorizing the Iowa Insurance Division to provide a copy of this complaint form and attachments to the insurance company, producer or agent that is the subject of your complaint.
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