Form Oci 51-005 - 2003 Wisconsin Insurance Complaint Form

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INSURANCE COMPLAINT FORM
State of Wisconsin
Office of the Commissioner of Insurance
125 South Webster Street
Complaint Phone Numbers (608) 266-0103 In Madison
P.O. Box 7873
1-800-236-8517 Statewide
Madison, WI 53707-7873
oci.wi.gov
Fax Number
(608) 264-8115
The Office of the Commissioner of Insurance assists consumers with their insurance problems. In order for us to investigate your
complaint, please complete this form as thoroughly as you can and return it to us at the address shown above. A copy of your com-
plaint will be sent to the company or agent with a request to respond directly to you and to advise our office of the action taken. You
should hear from the company or agent in about 25 days from the date you send us your complaint. When we receive the information
from the company or agent, we will review the file to determine what action we can take. We will notify you of our determination. If our
office is unable to obtain the resolution you desired, you may consider contacting a private attorney for advice. If your complaint
involved a claim dispute, you may want to contact your county's small claims court.
TYPE OR PRINT CLEARLY WITH A BLACK PEN. COMPLETE BOTH SIDES OF THIS FORM.
1. Your Name
Street Address
City
State
Zip Code
WI
Phone number where we can reach you between 8:00 - 4:30 p.m. (
)
-
2. Name of Insurance Company Involved
(Please provide the PRECISE NAME of the insurance company. Incorrect names will delay the
handling of your complaint. The name of the company can be found on your insurance policy,
usually on the first page.)
3. I am filing this complaint as:
Insured
Agent
Third-Party
Provider
Other
4. Type of Insurance
Auto
Individual Acc/Health
Business
Life/Annuity
Home
Group Acc/Health
Other
5. Name of Insurance Agent Who Sold the Insurance (Not the same as 2., above)
6. Name and Address of Insurance Agency, If Applicable (Not the same as 2., above)
7. Name of Policyholder (if other than 1., above)
8. Policy or Certificate #
9. Date Policy or Certificate Was Sold
10. State in Which Policy or Certificate Was Sold
WI
11. Claim or File #, If Applicable
12. Date Loss Occurred or Began, If Applicable
OCI 51-005 (R 04/2003)
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