Consumer Complaint Form

Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 01-16-2021

Please Note: Entry of accented characters such as ¿, é, á and ñ are not supported in this form.

Complainant's Information

Are you the insured?

Yes

What is your relationship to the insured?

*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:

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

Will you be mailing or faxing additional supporting information?

If mailing supporting documents, please include a copy of this form and mail to:

Department of Consumer & Business Services
Division of Financial Regulation – Consumer Advocacy & Education - 2
P.O. Box 14480
Salem, OR 97309-0405

or FAX supporting documents along with a copy of this form to: (503) 378-4351

Email Confirmation

*Do you wish to receive email confirmation?

Yes