Name of Insurance Company:
Policy#
Name & Address of Broker or Agent:
(Group Health) Name of Group or Employee:
Group #:
Type of Insurance (Check One):
Auto      Fire      Group Health      Individual Health		Annuity Life Credit Life/Credit Disability Other
Type of Claim:
(Health Insurance):
Date of Service
Date Claim Sent to Co.
Name of Doctor/Hospital
(Auto/Homeowners/Property Insurance):
Date of accident
Location of accident
Type of Problem (Select One or More):	Claim Denial/Dispute/Delay Health Claim Delayed Coordination of Benefits Misrepresentation by Agent or Company Cancellation or Renewal Misquoted Premium Payment not Credited Refund Due Policy Not Received Cash/Surrender or Value Not Received
Briefly Describe Your Complaint:
How would you like to see your complaint resolved?

Your Name:
Insured's Name (If Different):
Date of Birth:		Ward#
Mailing Address (Line 1):
Mailing Address (Line 2):
City:
State:		Zip Code:
Daytime Phone:
Email: