Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 09-29-2020


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:
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
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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

Authorization

<By completing this Consumer Complaint and submitting it to the Arizona Department of Insurance and Financial Institutions, I attest that the information provided to the Department of Insurance and Financial Institutions 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.>