Complaint Report Form - Louisiana Department Of Insurance Page 4
Download a blank fillable Complaint Report Form - Louisiana Department Of Insurance in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Complaint Report Form - Louisiana Department Of Insurance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Section III
Yes
No
Do you have an attorney representing you?
Yes
No
Is there any court action pending?
Yes
No
Have you previously reported this problem to our office or any other agency?
If yes, to whom?
File number (if applicable):
Please check the reasons that apply to your complaint.
Claim Denial
Claim Delay
Rate
Cancellation/Nonrenewal
Premium Refund
Agent Handling
Unfair Offer/Payment
Other:
Describe your problem in your own words. If more space is needed, please use extra sheets. Enclose copies
(NOT ORIGINALS) of available documentation relative to your complaint, including any applicable ID cards,
front and back.
What do you consider to be a fair resolution to your problem?
Please read and sign the following statement:
To the best of my knowledge, the information contained herein is true and accurate. I understand that a
copy of this form and any or all of the information attached may be sent to the party complained against.
(Signature)
(Date)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal