Consumer Complaint Form printable pdf download

LIFE AND HEALTH

Minnesota Insurance Division Consumer Complaint Form

(This

form is only for the use of Minnesota residents.)

Thank you for contacting the MN Department of Commerce Consumer Protection and Education

Division. Please provide the information requested below and allow sufficient time for us to

complete our inquiry. A copy of this form and any or all information you provide may be sent to

the party complained against.

1. Complainant

Your Name: _________________________________________________________________

Street Address: ______________________________________________________________

City: ____________________________________ State: _____ ZIP Code: ______________

Home Phone: _______________________

Work Phone: _____________________

Email Address: ______________________________________________________________

2. Insured

Name (if same, write "same"): __________________________________________________

Relationship to the insured: __________________________________________________

3. Who is the complaint against?

Name of Company, Agent/Broker, etc.: ____________________________________________

Street Address: ______________________________________________________________

City: _______________________________________ State: ____ ZIP Code: ____________

Name of Company, Agent/Broker, etc.: ____________________________________________

Street Address: ______________________________________________________________

City: _______________________________________ State: ____ ZIP Code: ____________

Name of Company, Agent/Broker, etc.: ____________________________________________

Street Address: ______________________________________________________________

City:

State:

ZIP Code:

4. Type of Insurance Involved (pick one)

___ Individual Life

___ Group Life

___ Long Term Care

___ Individual Health

___ Group Health

___ Dental

__ Workers Compensation

_____ Medicare Supplement

___ Other

Consumer Complaint Form