Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 09-19-2018

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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

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:
Kansas Insurance Department
420 SW 9th Street
Topeka, KS 66612-1678
or FAX supporting documents along with a copy of this form to: (785) 296-5806

Authorization

The Insurance Commissioner is authorized to send a copy of this complaint and any follow-up documents to any insurance company or agent/agency in order to investigate my concerns. I authorize the release of all 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, as well as become accessible to others under the Kansas Open Records Act. Finally, I declare and verify under penalty of perjury and the laws of Kansas that all of the above information is true and correct to the best of my knowledge.
*
Agree