Consumer Complaint Form

Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 12-09-2019

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:

Consumer Protection Division
Arizona Department of Insurance
100 N. 15th Ave., Ste. 102
Phoenix, AZ 85007-2624

or EMAIL supporting document along with a copy of this form to consumercomplaint@azinsurance.gov

Authorization

Authorization

Yes