Consumer Complaint Form (Page 2 of 2) in pdf

Consumer Complaint Form Page 2

5. Policy Information

Policy Number: _____________________________________________________________

Group or Certificate Number:__________________________________________________

Name of Employer/Association (if group insurance) _________________________________

Effective Date: _____________________________________________________________

6. Claim Information

Claim Number: ______________________________________________________________

Date of Loss/Treatment: _______________________________________________________

7. Reason for Complaint (check one or more)

___ Claim Denial

___ Claim Dispute /Delay

___ Sales /Service

___ Premium /Rating Problem

___ Cancellation /Non-Renewal

___ Medical Necessity / Usual & Customary Reduction

__ Other (please specify) ________________________________

Details of my complaint: (Please attach copies of all relevant documents including most recent

correspondence from the company)

(Please attach additional sheets as necessary)

I hereby affirm that the foregoing statements and photocopies of all attached documents are true

and correct.

Date

Signature of Complainant

Mail written complaints to:

Minnesota Department of Commerce

Attn: Consumer Protection & Education

Division, 85 7th Place East, Suite 500,

St. Paul, MN 55101

Consumer Complaint Form Page 2