Complaint Report Form - Louisiana Department Of Insurance Page 3
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4Louisiana Department of Insurance
P.O. Box 94214, Baton Rouge, LA 70804-9214
Call toll free, 1-800-259-5300; Locally, call 225-342-5900
PLEASE TYPE OR PRINT CLEARLY
Section I
Your Name:
Home Phone:
Address:
Work Phone:
City:
State:
Zip:
Cell Phone:
Insured:
Email:
Claimant:
Date of birth:
Social Security # (last four digits):
Under 25
25 – 49
50 – 64
65 +
Age Group:
Section II
Who is the complaint against? (Full and exact name of the company, broker, agent, or adjuster)
Address (if known)
What type of coverage does this involve?
Life
Homeowners
Bail Bonds
Worker’s Compensation
Health
Long Term Care
Commercial
Disability
Auto
Credit
Annuity
Medicare Supplement
Other:
If involving group insurance, please provide the name of the employer:
Policy Number:
Group Number:
Claim Number:
If your complaint is against another person’s insurance company, that person’s name, contact information,
and policy number:
Date of loss:
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Parent category: Legal