Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 06-20-2019

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

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:
Nebraska Department of Insurance
PO Box 82089
Lincoln, NE 68501-2089
or FAX supporting documents along with a copy of this form to: (402) 471-6559

Authorization

I understand my complaint will be shared with the insurance company and agent involved. I acknowledge and authorize the release of medical, personally identifiable, and/or protected information to the extent necessary to complete the investigation, including the sharing of this information with other governmental agencies. I further acknowledge that the State Tort Claims Act provides that neither the Department of Insurance staff nor the State of Nebraska may be held liable for consequences that flow from their efforts because such efforts are discretionary acts.
*
Agree