Life And Health Insurance Complaint/appeal Form
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Life and Health Insurance Complaint/Appeal Form
Mail to:
State Corporation Commission
Bureau of Insurance
Life and Health Division
P.O. Box 1157
Richmond, VA 23218
1-877-310-6560 or TDD 804-371-9206; Fax# 804-371-9944
You can call the Bureau for general information and assistance. To file a complaint or request assistance in
appealing a denial, please complete this form. We may have to ask you for more information.
I am filing (check all applicable):
A complaint against a(n):
Insurance company
Insurance Agent/Web Broker
Navigator
Other Assister
A request for assistance in appealing an adverse determination made by a Managed Care Insurance Plan
Type of Insurance Coverage:
Health (
HMO
PPO
Other)
Dental
Long-Term Care
Medigap
Disability
Life
Annuity
Credit
Other ________________________
If you checked HMO, PPO or Dental, was your coverage purchased through the Health Insurance Exchange/
Marketplace or SHOP Marketplace?
Yes
No
I don’t know
If Yes, do you have a Multi-state Plan?
Yes
No
I don’t know
If you checked Health, HMO or PPO under Type of Insurance Coverage and you have Individual coverage or
coverage through a Small Employer, what level of coverage do you have?
Platinum
Gold
Silver
Bronze
Catastrophic
None of these
I don’t know
Please provide information about the insured person who needs help.
Name: Mr. Ms.__________________________________________________ Date of Birth: ____________
Address: _______________________________________________________________________________
Street
City
ST
Zip Code
Home Telephone No.: (_____)_______________ Cell Telephone No.: (_____)________________________
Business Telephone No.: (______)______________ E-Mail: _____________________________________
Complete this section if you are NOT the insured person and you are requesting help on behalf of the
insured person. Note: In order for the Bureau to help the insured person, the individual will have to
sign the form.
Name/Relationship to the Insured Person:
Mr.
Ms.____________________________________________
Address: _______________________________________________________________________________
Street
City
ST
Zip Code
Home Telephone No.: (_____)_______________ Cell Telephone No.: (_____)_______________________
Business Telephone No.: (______)______________ E-Mail: _____________________________________
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