Form DOI-4000-1007 "Consumer Complaint" - Nebraska

What Is Form DOI-4000-1007?

This is a legal form that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the Nebraska Department of Insurance;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOI-4000-1007 by clicking the link below or browse more documents and templates provided by the Nebraska Department of Insurance.

ADVERTISEMENT
ADVERTISEMENT

Download Form DOI-4000-1007 "Consumer Complaint" - Nebraska

1229 times
Rate (4.8 / 5) 83 votes
STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
P
R
B
R. R
ETE
ICKETTS
RUCE
AMGE
G
D
OVERNOR
IRECTOR
CONSUMER COMPLAINT
Mr.
Mrs.
Ms.
Complaint Made By:
P
P
(Last Name)
(First Name)
(Middle)
LEASE
RINT
Home Address:
(Address)
(City)
(State)
(Zip Code)
Phone Number:
(
)
Alternate Phone Number:
(
)
Email Address:
Insured Information (if different from above):
Other Parties involved in this problem:
Complaint is directed against:
Insurer:
Agent or Agency:
Policy or Claim #:
Date of Loss:
(Circle one)
(If claim)
Policy Type:  Life  Group Health Individual Health  Auto  Property  Other
P
C
I
A
G
:
<25
25-49
50-64
65+
LEASE
IRCLE
NSURED
S
GE
ROUP
Details of Complaint: Please note, a copy of your complaint will be sent to the company and/or the agent.
(An additional page may be used, if necessary)
I understand my complaint will be shared with the insurance company and agent involved. I acknowledge and authorize the release of
medical, personally identifiable, and/or protected information to the extent necessary to complete the investigation including the
sharing of this information with other governmental agencies. I further acknowledge that the State Tort Claims Act provides that neither
the Department of Insurance staff nor the State of Nebraska may be held liable for consequences that flow from their efforts because
such efforts are discretionary acts.
Date:
Signature
PO Box 82089  Lincoln, NE 68501-2089
Phone: 402-471-2201  Fax: 402-471-4610  TDD 1-800-833-7352
Consumer Toll-Free Hotline: 1-877-564-7323  Email:
DOI.ConsumerAffairs@nebraska.gov
www.doi.nebraska.gov
An Equal Opportunity Employer
DOI-4000-1007
Rev. 4/20
STATE OF NEBRASKA
DEPARTMENT OF INSURANCE
P
R
B
R. R
ETE
ICKETTS
RUCE
AMGE
G
D
OVERNOR
IRECTOR
CONSUMER COMPLAINT
Mr.
Mrs.
Ms.
Complaint Made By:
P
P
(Last Name)
(First Name)
(Middle)
LEASE
RINT
Home Address:
(Address)
(City)
(State)
(Zip Code)
Phone Number:
(
)
Alternate Phone Number:
(
)
Email Address:
Insured Information (if different from above):
Other Parties involved in this problem:
Complaint is directed against:
Insurer:
Agent or Agency:
Policy or Claim #:
Date of Loss:
(Circle one)
(If claim)
Policy Type:  Life  Group Health Individual Health  Auto  Property  Other
P
C
I
A
G
:
<25
25-49
50-64
65+
LEASE
IRCLE
NSURED
S
GE
ROUP
Details of Complaint: Please note, a copy of your complaint will be sent to the company and/or the agent.
(An additional page may be used, if necessary)
I understand my complaint will be shared with the insurance company and agent involved. I acknowledge and authorize the release of
medical, personally identifiable, and/or protected information to the extent necessary to complete the investigation including the
sharing of this information with other governmental agencies. I further acknowledge that the State Tort Claims Act provides that neither
the Department of Insurance staff nor the State of Nebraska may be held liable for consequences that flow from their efforts because
such efforts are discretionary acts.
Date:
Signature
PO Box 82089  Lincoln, NE 68501-2089
Phone: 402-471-2201  Fax: 402-471-4610  TDD 1-800-833-7352
Consumer Toll-Free Hotline: 1-877-564-7323  Email:
DOI.ConsumerAffairs@nebraska.gov
www.doi.nebraska.gov
An Equal Opportunity Employer
DOI-4000-1007
Rev. 4/20