Consumer Complaint
Required Fields are marked with an asterisk.
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Date: 01-16-2021
Complainant's Information
Are you the insured?
Yes
No
What is your relationship to the insured?
Select One
Beneficiary
Child
Claimant (other party’s insurer)
Healthcare Provider
Legal Representative
Other
Parent
Self
Spouse
State or Federal Agency
Are you currently represented by an attorney for this matter?
Yes
No
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First Name:
Middle Name:
*
Last Name:
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Address Line 1:
Address Line 2:
Address Line 3:
Address Line 4:
Address Line 5:
Address Line 6:
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City:
*
State:
Select One
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
Armed Forces Americas
Armed Forces Other
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
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Illinois
Indiana
Iowa
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Marshall Islands
Maryland
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NAIC
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Northwest Territories
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Ohio
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Ontario
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Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
US Virgin Islands
Unknown State
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Yukon Territory
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ZIP:
County:
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Abbeville
Aiken
Allendale
Anderson
Bamberg
Barnwell
Beaufort
Berkeley
Calhoun
Charleston
Cherokee
Chester
Chesterfield
Clarendon
Colleton
Darlington
Dillon
Dorchester
Edgefield
Fairfield
Florence
Georgetown
Greenville
Greenwood
Hampton
Horry
Jasper
Kershaw
Lancaster
Laurens
Lee
Lexington
Marion
Marlboro
McCormick
Newberry
Oconee
Orangeburg
Out of State
Pickens
Richland
Saluda
Spartanburg
Sumter
Union
Williamsburg
York
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Country:
United States
Canada
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Cura‡ao
Cyprus
Czech Republic
C“te d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin(French Part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch Part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
Unidentified
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
land Islands
International Zip:
Email Address
Reenter Email:
*
Phone Number:
EXT:
Alternate Phone Number:
EXT:
How do you prefer to be contacted? :
Select One
Alternate number with message being left
Alternate number without message being left
Alternate Phone Number
Email
Fax
Mail
Phone
Phone number with message being left
Phone number without message being left
Insured's Information(If different than above)
First Name:
Middle Name:
Last Name:
Other Parties involved in this problem
First Name:
Last Name:
Description:
First Name:
Last Name:
Description:
First Name:
Last Name:
Description:
First Name:
Last Name:
Description:
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
No
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:
Select One
25 to 49
50 to 64
65+
< 25
Unknown
Amount in Dispute:
*
Type of Insurance:
Annuity
Auto
Bail Bonds
Commercial
Dental
Disability
Group Health
Home
Individual Health
Life
Long Term Care
Medicare Supplement
Other
Title
Worker’s Comp
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Reason For Complaint:
Adjuster Handling
Agent Handling
Cancellation
Claim Delay
Claim Denial
Information Requested
Misrepresentation
Non-Renewal
Other
Policy Problem
Premium Problem
Unsatisfactory Offer
Other Desc:
Other Desc:
Details and Supporting Documents
*
Details Of Complaint:
4000 characters remaining.
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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
No
Email Confirmation
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Do you wish to receive email confirmation?
Yes
No
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.
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Authorization
Yes
No