Consumer Complaint Form

Required Fields are marked with an asterisk. *

Date: 09-16-2019

Complainant's Information

Are you the insured?

Yes

What is your relationship to the insured?

Are you currently represented by an attorney for this matter?

Yes

*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?:

Are you presently in litigation?

Yes

Have you litigated your claim?

Yes

If you answered "Yes" what was the court's decision?:

4000 characters remaining.

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.

*What do you consider to be a fair resolution?:

4000 characters remaining.

Note: After final submission of this form you will be provided with an opportunity to attach supporting documents

Yes

If you are unable to upload documents with this complaint, will you be mailing or faxing additional 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.

Authorization

Yes