Consumer Complaint Form

Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 04-19-2021

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?

How was the Policy Purchased?:

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:

Nebraska Department of Insurance
PO Box 82089
Lincoln, NE 68501-2089

or FAX supporting documents along with a copy of this form to: (402) 471-4610

Email Confirmation

*Do you wish to receive email confirmation?

Yes

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