Complaint Form - The Guardian Life Insurance Company
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1
2Complaint Form
MEMBER ID NUMBER:
SUBSCRIBER NAME:
GROUP NUMBER:
(
)
ADDRESS:
HOME PHONE:
(
)
WORK PHONE:
(
)
FAX:
NAME AND ID NUMBER OF DENTAL OFFICE INVOLVED:
THIS COMPLAINT RELATES TO:
Subscriber
Dependent Name
PLEASE EXPLAIN YOUR COMPLAINT:
WHAT ACTION WOULD YOU LIKE GUARDIAN TO TAKE?
MEMBER (OR LEGAL GUARDIAN) SIGNATURE
DATE:
Please return the Complaint Form along with all related documents to the Quality of Care Liaison
at the return address shown within thirty (30) days from receipt. You will receive a response to
your written complaint within thirty (30) calendar days after Guardian receives the Complaint
Form.
VALID IN FLORIDA
The Guardian Life Insurance Company of America P.O. Box 4391, Woodland Hills, CA 91365-4391
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