Consumer Complaint Form

Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 04-23-2021

Complainant's Information

Are you the insured?

Yes

What is your relationship to the insured?

*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:

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:

How was the Policy Purchased?:

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.

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

Yes

If mailing supporting documents, please include a copy of this form and mail to:

Insurance Consumer Services Section
Arizona Department of Insurance and Financial Institutions
100 N. 15th Ave. Ste. 261
Phoenix, AZ 85007-2630

or EMAIL supporting document along with a copy of this form to insurance.consumers@difi.az.gov

The Arizona Department of Insurance and Financial Institutions provides equal access to communications for people with disabilities. Individuals requiring accommodation with a disability should call the Department`s ADA Coordinator at 602-364-3100.

Email Confirmation

*Do you wish to receive email confirmation?

Yes

Authorization

I declare, under penalty of perjury, that the information contained in this complaint, including all documents submitted with or in support of this complaint, are true, accurate, and based upon my personal knowledge. I understand that this complaint and/or certain information and documents related to this complaint may become a matter of public record, pursuant to state or federal law.

Authorization

Yes