PDF Missouri Consumer Complaint Report
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DIFP
Department of Insurance, Financial Institutions & Professional Registration
My complaint is against (one or more):
Consumer Complaint Report
Insurance company
Agent/producer
MAIL TO
Missouri DIFP PO Box 690 Jefferson City, MO 65102
800-726-7390 573-751-2640
TDD: 573-526-4536
Bail bond agent
Public adjuster
Please complete all information and enclose copies of correspondence and other papers that will help us investigate your complaint. Sign and date on back side at bottom. Note: A copy of this form and any of the enclosed information will be sent to the party you are complaining about. Send form and attachments to the above address.
PLEASE PRINT, TYPE OR WRITE CLEARLY IN BLACK OR BLUE INK
1 COMPLAINANT INFO
2 INSURED INFO (Person with insurance problem)
Mr. Ms.
AGE
1 - 24
25 - 49
50 - 6 4
65 +
LAST NAME
ADDRESS STREET
FIRST
CITY
COUNTY
(
)
PHONE
HOME
( CELL
EMAIL )
RELATIONSHIP TO INSURED
MI
STATE ZIP CODE
(
)
WORK
LAST NAME
ADDRESS Leave STREET blank if same as claimant CITY
EMPLOYER NAME (if group health policy)
POLICYHOLDER NAME
FIRST STATE ZIP CODE
3 INFO ON COMPANY/ PERSON THAT COMPLAINT IS ABOUT
4 POLICY INFORMATION
NAME OF COMPANY OR INDIVIDUAL YOU ARE COMPLAINING ABOUT
ADDRESS If known STREET
CITY
STATE ZIP CODE
GROUP or POLICY NUMBER ID or CERTIFICATE NUMBER CLAIM NUMBER AGENT NAME, if applicable
ISSUE DATE ISSUE DATE DATE OF LOSS
5 TYPE OF POLICY (Check one)
Homeowners Renters Mobile homeowners Private auto
Commercial auto Individual health Group health Individual life
Group life Workers' comp Disability Long-term care
Annuity Bond Title Warranty
Medigap (Med Supplement) Specify plan A-L Commercial/Business Other
GO TO BACK
Consumer Complaint Report, page 2 of 2
6 REASON FOR COMPLAINT (Check one)
Claim problem
Nonrenew/ Cancellation
Sales problem
Premium problem
Policy problem
7 DETAILS OF COMPLAINT (Attach separate sheet if needed)
Other
Missouri DIFP
7 SIGNATURE
I declare the information I have provided is true and accurate. I hereby authorize the insurer or persons or entities complained against to release all claim and policy information and documents, including medical records, to the Missouri Department of Insurance on request.
Signature of complainant
DATE
REVISED DECEMBER 2014
................
................
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