Consumer Complaint

1. Complainant
* Last name:* First name:MI:
*Street address:
*Home telephone number: (e.g.,(573) 555-1212) Work phone number:   Ext.
() ()
*Email address:
If you do not have an email address, please check this box.
2. Insured/policyholder
*Name (if same, write same):
Age of insured:
1-24 25-49 50-64 65+
3. Who is the complaint against?
*EXACT name of company, producer/agent etc.:
Street address:
City, State, Zip:
Employer name (if group policy) and policy number:
Group or Certificate number:
Policy or ID number:
Effective date:
Claim number:
Agent name (if applicable):
Date of loss:
4. *Type of insurance involved (check one):
Life and Health:Property and Casualty:
Annuity Bond
Individual life Title
Individual health Private auto
Group life Homeowners
Group health Commercial auto
Long term care Mobile homeowners
Disability Renters
Workers comp Warranty
Medicare advantage
Medicare supplement (specify plan A through L):
Other (specify):
5. *Reason for complaint (check one or more):
Claim problem
Claim delay
Sales problem
Premium problem
Policy problem
Other, please specify:
Details of my complaint:
(Please do not include Social Security Numbers on this form)

I declare the information I have provided is true and accurate. I hereby authorize the insurer or persons or entities, including third party administrators, complained against to release all claim and policy information and documents, including medical records, to the Missouri Department of Insurance on request.