Form Ps-4 - Insurance Compliant Form
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1
2COMMONWEALTH OF PENNSYLVANIA
INSURANCE COMPLAINT FORM
(PLEASE TYPE OR PRINT)
It is our goal to assist you in resolving your complaint as quickly as possible. Therefore, we ask that you
complete this form and return it to the office listed on the reverse side of this page. Please provide as much
information and documentation as you can. Within a few days following our receipt of your complaint, you will
receive a letter advising you of your file number, the name of the investigator assigned to assist you and
information on how to contact our office if you have questions. In general, you can expect the investigator to
contact you within thirty (30) days to advise you of our findings or the status of our review.
DAYTIME TELEPHONE
NAME:
HOME: (_____)_________________________
ADDRESS: _____________________________________________
WORK: (_____)_________________________
EMAIL: ________________________________
INSURED’S NAME: (IF OTHER THAN THE ABOVE) :
__________________________________________________________
INSURANCE CARD ID NUMBER:
1. Does this complaint involve an individual that is Medicare eligible?
(Y/N)
Auto
Medicare Supplement
2. Type of
Individual Life
Individual Health
Insurance:
Homeowners
Group Life
Long Term Care
Group Health
Annuity
HMO
Renters/Cond o
Commercial
Viatical
Medicaid
Flood
Medicare
Title
Medicare Advantage
3. Type of
Cancellation/Nonrenewal
Claim Handling
Billing/Premium Dispute
Problem:
Sales Misrepresentation
Other (specify) _____________________________________
4. (A) If your problem involves an insurance company, give the full name of the company:
(B) If your problem involves an agent or broker, give his/her full name, address and phone number.
5. Policy Number: ________________________ In what State was this policy sold? ________________
6. Date & location of loss: __________________________ Claim #: ______________________________
7. Have you previously reported this problem to our office or any other agency?
Yes
No
PS-4 (REV. 12/15)
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