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

Are you the insured?

Yes

What is your relationship to the insured?

Are you currently represented by an attorney for this matter?

Yes

*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.

*What do you consider to be a fair resolution?:

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:

Missouri Department of Insurance
Attn: Consumer Affairs
P O Box 690
Jefferson City, MO 65101-0690

or FAX supporting documents along with a copy of this form to: (573) 526-4898

Email Confirmation

*Do you wish to receive email confirmation?

Yes

Authorization

I declare the information provided is true and accurate. I hereby authorize the insurer or persons or entities complained against to release all claim and policy information and documents, including medical records, to the Missouri Department of Insurance on request.

Agree