Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 05-24-2018


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

4000 characters remaining.
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:
Consumer Affairs Division
Arizona Department of Insurance
2910 N. 44th Street #210
Phoenix, AZ 85018-7269
or EMAIL supporting document along with a copy of this form to consumercomplaint@azinsurance.gov

Authorization

By completing this Request for Assistance Form and sending it to the Arizona Department of Insurance, I attest that the information provided to the Department of Insurance is accurate to the best of my knowledge and ability, and that I understand that the facts relating to this complaint will become a matter of public record, pursuant to Arizona law.