Consumer Complaint Form - Nevada Division Of Insurance
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1
2Department of Business and Industry
Nevada Division of Insurance
CONSUMER COMPLAINT FORM
Mail to:
1818 E. College Pkwy #103
Mail to:
2501 E. Sahara Ave #302
Carson City, NV 89706
Las Vegas, NV 89104
775-687-0700 Phone
702-486-4009 Phone
775-687-0797 Fax
702-486-4007 Fax
Initial this box if you want the Division of Insurance to treat records of your Consumer Complaint
as confidential.
Are you represented by an attorney? Yes ___ No ___
If yes, please be advised the Division may not be able to intercede on your behalf.
Your contact information
Name: _________________________________________________________________________________________
Address: _____________________________________________________________ Apt. #: _______
City: _________________________________________
State: ________
Zip: _____________
Home Phone: ________________________________ Work phone: ______________________________________
Cell Phone: ___________________________
Email: __________________________________________________
(if complaint is against other party’s insurance)
Policyholder information
Name of policyholder: _____________________________________________
Insurance information
Insurance company the complaint is against:
______________________________________________________________________________________
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Type of policy:
Group
Individual
Unknown
Policy No: _______________________________________
Claim No: ____________________
If auto related, License Plate No: _____________________
Date of Loss/Accident/Incident: ____________________
Type of
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insurance:
Auto
Home/Condo/Renters
Health
Life
Dental
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Long Term Care
Medical Supplemental
Ext. Warranty/Service Contract
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Other:
Agent/Agency Name: _____________________________________________________
DOI 310 (rev 07/22/2014) Page 1 of 2
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Parent category: Legal