Consumer Complaint

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Date: 12-13-2018

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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:
Department of Consumer & Business Services
Insurance Division
P.O. Box 14480
Salem, OR 97309-0405
or FAX supporting documents along with a copy of this form to: (503) 378-4351

Authorization