Form Oci 51-005 - 2015 Wisconsin Insurance Complaint Form (Page 2 of 3) in pdf

Form Oci 51-005 - 2015 Wisconsin Insurance Complaint Form Page 2

13. 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?

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 07/2015)

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Form Oci 51-005 - 2015 Wisconsin Insurance Complaint Form Page 2