Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 09-16-2019

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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:
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

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