Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 09-19-2018

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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:
Arkansas Insurance Department
Consumer Services Division
1200 West Third Street
Little Rock, AR 72201-1904
or FAX supporting documents along with a copy of this form to: (501) 371-2749

Authorization

The Insurance Commissioner is authorized to send a copy of this complaint and any follow-up documents to any insurance company or agent/agency in order to investigate my concerns. I authorize the release of all relevant information, including medical records, to the Insurance Commissioner’s office for its review of this matter. I understand the Insurance Commissioner’s office cannot act as my attorney, cannot file a private action on my behalf, and cannot provide legal advice, I further understand and agree that the contents herein may be forwarded to other appropriate state or federal agencies, as well as become accessible to others under the Arkansas Freedom of Information Law. Finally, I declare and verify under penalty of perjury and the laws of Arkansas that all of the above information is true and correct to the best of my knowledge.
*
Agree