Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 12-12-2018

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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:
State of Rhode Island and Providence Plantations
DEPARTMENT OF BUSINESS REGULATION
Insurance Division
1511 Pontiac Avenue, Bldg 69-2
Cranston, RI 02902
or FAX supporting documents along with a copy of this form to: (401) 462-9602

Authorization

I authorize the Rhode Island Insurance Division to provide a copy of this complaint to the insurance company, producer, or other licensee that is the subject of my complaint.