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.