Consumer Complaint

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Date: 04-23-2021

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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:
The State of New Hampshire
Insurance Department
21 South Fruit Street
Suite 14
Concord, NH 03301
or EMAIL supporting document along with a copy of this form to TDD Access: Relay NH 1-800-735-2964
or FAX supporting documents along with a copy of this form to: (603) 271-7066

Email Confirmation

Authorization

The submittal of this complaint form will initiate an investigation of any Department licensee who is the subject of the identified complaint. Pursuant to RSA 400-A:16, II the Department will request and receive information and documentation, relevant to this investigation, from the named parties. Please note relevant information may include medical records. Also, the Department may share with the Department licensee any medical information and/or records provided in connection with this complaint.
*
Agree