Consumer Complaint Form

Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 01-16-2021

Please Note: Entry of accented characters such as ¿, é, á and ñ are not supported in this form.

Complainant's Information

*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:

How do you prefer to be contacted? :

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:

In what state did you purchase this plan?

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

Will you be mailing or faxing additional supporting information?

If mailing supporting documents, please include a copy of this form and mail to:

Kansas Insurance Department
1300 SW Arrowhead
Topeka, KS 66604

or FAX supporting documents along with a copy of this form to: (785) 296-5806

Email Confirmation

*Do you wish to receive email confirmation?

Yes

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