Life And Health Insurance Complaint/appeal Form Page 2
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2Complete Name of Insurance Company: _____________________________________________________
Policy Number
Certificate Number
ID Number: __________________________________________
Source of Insurance Coverage:
Group ______________________________________
Individual
(Name of employer or group association)
If your complaint involves an Agent, Web Broker, Navigator, or other Assister, (circle one) please provide the
following:
Name: ________________________________
Organization/ Agency: _____________________________
Address: _______________________________________________________________________________
Street
City
ST
Zip Code
Web Broker Website Address: ______________________________________________________________
Describe the issues involved in your complaint or appeal. Attach a separate sheet if necessary, and
attach correspondence from insurer if applicable.
I am enclosing copies of all correspondence or other papers relating to this matter that may assist the
Bureau of Insurance (BOI) in its evaluation of my complaint/appeal. I understand and agree that the
BOI may send a copy of this form and any or all of the enclosed information to the party complained
against, other regulated entities, or the appropriate state or federal agency.
I also authorize the
insurance company to release all medical records relating to this complaint/appeal to the BOI, and I
authorize the BOI to release medical records relating to this complaint/appeal to the insurance
company. I also agree that by signing this form, I authorize the BOI to obtain any other information
required to evaluate my complaint/appeal.
Signature of person requesting assistance: ____________________________________________________
Signature of Insured Person
(if 18 or over and if different from above): ______________________________________________________
Date: _______________________________
For questions concerning a complaint, you may contact the BOI’s Consumer Services Section at 804-371-9691
or toll free in Virginia at 1-800-552-7945 or 1-877-310-6560. If you have any questions about filing an appeal,
you may contact the BOI’s Office of the Managed Care Ombudsman at 804-371-9032 or toll free at 1-877-310-
6560.
Rev 6/15
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