Complaint Questionnaire Form - Arizona Department Of Insurance printable pdf download

Complaint Questionnaire Form - Arizona Department Of Insurance

Arizona Department of Insurance

2910 N. 44th St., #210 • • • • Phoenix, AZ 85018

Tel: 602-912-8444 • • • • Fax: 602-954-7008

COMPLAINT QUESTIONNAIRE

INSTRUCTIONS

Give us a brief statement as to what the insurance company/agent has done or has failed to do; and

what you would like the Department of Insurance to do to help you

Date:

Phone Number:

Complainant:

Last Name

First Name

Middle Initial

Address:

City:

State:

Zip:

Insured: (If other than complainant):

Address:

City:

State:

Zip:

Name of Insurance Company:

Policy:

Type of Insurance:

Effective Date of Policy:

(Life, hospitalization, auto, fire, etc.)

State where policy was purchase:

If your complaint is regarding your insurer denying payment for a health-related claim, which of the

following best describes your situation?

Company denied; saying the service was not medically necessary.

Not authorizing; or pre-authorizing a covered service.

Denying a referral to a specialist.

Other; explain

I submit the following information and represent that such information is accurate to the best of my knowledge and ability:

You may use reverse side to complete your statement

By my signature, I hereby acknowledge that the facts relating to this complaint will become a matter of public record, pursuant to

Arizona law

Signature:

You will hear from us in writing as soon as we have definite information.

Persons with a disability may request that materials be presented in an alternative format by contacting the ADA

Coordinator at (602) 912-8456. Requests should be made as early as possible to allow time to obtain the materials in

an alternate format.

Complaint Questionnaire Form - Arizona Department Of Insurance