Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 10-19-2018

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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:
Oklahoma Insurance Department
Consumer Assistance/Claims Division
3625 NW 56th Street, Ste. 100
Oklahoma City, OK 73112
or FAX supporting documents along with a copy of this form to: (405) 521-6652

Authorization

With this knowledge, I give my consent to the release of all information in my medical records including any information concerning my identity and release the OKLAHOMA INSURANCE DEPARTMENT and its duly authorized agents and employees from any liability in connection with the release of the information contained herein.