Consumer Complaint Form

Required Fields are marked with an asterisk. *

Date: 04-04-2020

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:

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

Email Confirmation

*Do you wish to receive email confirmation?

Yes

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 Carolinaâ€™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.

Authorization

Yes