Form Ps-4 - Insurance Compliant Form (Page 2 of 2) in pdf

Form Ps-4 - Insurance Compliant Form Page 2

Are you represented by an attorney?

Yes

No If yes, please give name, address and telephone #:

Note: If you have proceeded with litigation against the company and/or agent we will not be able to assist you until the litigation

has been completed and the court has found misconduct on the part of these parties.

9. Briefly describe your problem and state how you feel it should be resolved. Copies of your policy, correspondence or

other supporting documentation will assist us in understanding or evaluating the issues, please include this

documentation with your complaint form. If more space is needed to describe your problem, please attach additional

sheets.

PLEASE READ, SIGN AND DATE THE STATEMENT BELOW:

I CERTIFY THAT THE INFORMATION THAT I HAVE GIVEN ABOVE IS TRUE AND ACCURATE TO THE

BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT A COPY OF THIS FORM AND

ATTACHMENTS MAY BE FORWARDED TO THE INSURANCE COMPANY, AGENT OR BROKER

INVOLVED.

(Signature)

(Date)

(IF YOUR COMPLAINT INVOLVES A MEDICAL ISSUE AND/OR CREDIT INFORMATION)

Please circle either Medical Issue, Credit Information or Both.

I AUTHORIZE__________________________________ (Name of Insurance Company) TO RELEASE TO THE

PENNSYLVANIA INSURANCE DEPARTMENT ANY MEDICAL OR CREDIT INFORMATION THAT MAY

BE PERTINENT TO THE RESOLUTION OF MY COMPLAINT.

(Signature)

(Date)

Mail or Fax Complaint Form to:

Pennsylvania Insurance Department

Bureau of Consumer Services

Room 1209, Strawberry Square

Harrisburg, PA 17120

Fax: (717) 787-8585

Toll Free Consumer Hotline: 1-877-881-6388

Please feel free to submit your question or complaint on-line at:

Website:

PS-4 (REV. 12/15)

Form Ps-4 - Insurance Compliant Form Page 2