Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 12-13-2018


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.
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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:
Office of Superintendent of Insurance
PO Box 1689
Santa Fe, NM 87504-1689
or EMAIL supporting document along with a copy of this form to: osi.consumer@state.nm.us

Authorization

The information provided on and with this form is true and correct to the best of my knowledge and belief. I am enclosing copies of any correspondence or other documentation in my possession that may be of assistance. I fully understand that a copy of this form and any or all of the enclosed information may be forward to the involved insurance company or agent. I also understand that the facts relating to this matter will become a matter of public record pursuant to New Mexico law once my file is closed.