Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 11-20-2018

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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:
Delaware Department of Insurance
Consumer Services Division
841 Silver Lake Blvd
Dover, DE 19904
or FAX supporting documents along with a copy of this form to: (302) 739-6278

Authorization

I authorize the Delaware Insurance Commissioner's office to send a copy of this complaint and any follow-up documents to any applicable company or agent/agency in order to investigate my concerns. I authorize the release of any 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.