Form Oci 51-005 - 2003 Wisconsin Insurance Complaint Form Page 2
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313. Please describe your problem in detail. Attach additional pages, if necessary. Please include copies of important papers,
letters, or other information, if they relate to your problem.
PLEASE SEND COPIES ONLY—NO ORIGINALS AND NO PHOTOS.
Extra Page
14. Please indicate how you think your problem should be resolved.
15. Have you previously reported this problem to us or any other governmental agency?
No
If yes, state which agency and what action was taken?
Yes
Consent to Release Information
The information I have given above is true and accurate to the best of my knowledge and belief. This information may be
forwarded to the insurance company and/or agent involved. Any medical information which I have provided, may be shared
with the insurance company, if necessary for the investigation of this matter. I understand that under Wisconsin's Open
Records Law all information which is in my file, including personal and health information, may become a public record once
my file is closed. Only actual medical records which are obtained from a health care provider are confidential under
s. 146.82, Wis. Stat.
Signature
Date
OCI 51-005 (R 04/2003)
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Parent category: Legal