Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 11-20-2018


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

Authorization

I declare that the information I have provided is true and accurate to the best of my knowledge. This information will be forwarded to the insurance company (and/or other party that is the subject of your complaint) for the investigation of this matter. I understand that, under South Carolina’s Freedom of Information Act, this complaint becomes a public record once my file is closed (medical and personal records will remain confidential). By submitting this form, I am authorizing the SC Department of Insurance to pursue an investigation into my complaint and the party(ies) complained against to release all relevant information, documents, and records to the SC Department of Insurance.