Complaint Questionnaire - Arizona Department Of Insurance printable pdf download

Arizona Department of Insurance

Investigations

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

Tel: 602-912-8444

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.

)

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 the 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 disabilities may request reasonable accommodations such as interpreters,

alternative formats or assistance with physical accessibility. Requests for accommodations

must be made with 72 hours prior notice by contacting Don Harris at (602) 912-8402.

Complaint Questionnaire - Arizona Department Of Insurance