Consumer Complaint Report
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DIFP
Consumer
MAIL TO
Missouri DIFP
PO Box 690
Complaint
Jefferson City, MO 65102
Department of Insurance,
800-726-7390
Financial Institutions &
Report
573-751-2640
Professional Registration
TDD: 573-526-4536
My complaint is against
Insurance company
Agent/producer
Bail bond agent
Public adjuster
(one or more):
Please complete all information and enclose copies of correspondence and other papers that will help us
investigate your complaint. Sign and date on back side at bottom.
Note:
A copy of this form and any of the enclosed
information will be sent to the party you are complaining about. Send form and attachments to the above address.
PLEASE PRINT, TYPE OR WRITE CLEARLY IN BLACK OR BLUE INK
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2
COMPLAINANT INFO
INSURED INFO (Person with insurance problem)
AGE
Mr.
Ms.
1 - 24
25 - 49
50 - 6 4
65 +
LAST NAME
FIRST
MI
LAST NAME
FIRST
ADDRESS
ADDRESS
STREET
STREET
Leave
blank if
same as
CITY
STATE
ZIP CODE
CITY
STATE ZIP CODE
claimant
EMPLOYER NAME
COUNTY
EMAIL
(if group
health policy)
(
)
(
)
(
)
PHONE
HOME
CELL
WORK
POLICY-
HOLDER
NAME
RELATIONSHIP TO INSURED
3
4
INFO ON COMPANY/ PERSON THAT COMPLAINT IS ABOUT
POLICY INFORMATION
or
GROUP
POLICY NUMBER
NAME OF COMPANY OR INDIVIDUAL YOU ARE COMPLAINING ABOUT
ISSUE DATE
ADDRESS
If known STREET
or
ISSUE DATE
ID
CERTIFICATE NUMBER
CLAIM NUMBER
DATE OF LOSS
CITY
STATE
ZIP CODE
AGENT NAME, if applicable
5
TYPE OF POLICY (Check one)
Homeowners
Commercial auto
Group life
Annuity
Medigap (Med Supplement)
Specify plan A-L
Renters
Individual health
Workers’ comp
Bond
Commercial/Business
Mobile homeowners
Group health
Disability
Title
Private auto
Individual life
Long-term care
Warranty
Other
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