Consumer Complaint

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Date: 05-24-2018


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.



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

Authorization

By completing this Request for Assistance Form and sending it to the Office of the Insurance Commissioner of Puerto Rico, I attest that the information provided to the Office of the Insurance Commissioner is accurate to the best of my knowledge and ability, and that I understand that the facts relating to this complaint will become a matter of public record, pursuant to Puerto Rico law.