"Consumer Complaint Form" - Connecticut

Consumer Complaint Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

Form Details:

  • Released on March 1, 2017;
  • The latest edition currently provided by the Connecticut Insurance Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut Insurance Department.

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Download "Consumer Complaint Form" - Connecticut

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STATE OF CONNECTICUT
INSURA N CE DEPARTMENT
Consumer Affairs Division
P.O. Box 816 – Hartford CT 06142‐0816
PHONE 860.297.3900 | FAX 860.297.3872
EMAIL insurance@ct.gov | WEBSITE www.ct.gov/cid
CONSUMER COMPLAINT FORM
Complainant Name: __________________________________________________________________________
Street: ______________________________________________________________________________________
City:
______________________________________ State: __________________ Zip Code: ____________
Daytime Phone: ______________________
Email: ________________________________________________
Relationship to Insured/Claimant: _______________________________________________________________
Name of Insured/Claimant
: ___________________________________________________
(If different than above)
Street: ______________________________________________________________________________________
City:
______________________________________ State: __________________ Zip Code: ____________
Type of Insurance:
Auto
Home/Renters
Life
Annuity
Commercial
Travel
Pet
Individual Health
Group Health - Employer Name: ___________________________
Disability
Dental
Long Term Care
Other ___________________________
Name of Insurance Company: ___________________________________________________________________
Policy # / Subscriber ID#:
___________________________________________________________________
If this complaint is related to a claims delay or claims denial:
Property & Casualty Complaints: Date of Loss: ____________________ Claim #: ______________________
Health or Dental Complaints:
Date(s) of Service: ______________________________________________
Name of Healthcare Provider: _____________________________________
Name of Agent/Agency
: ______________________________________________________________
(If applicable)
Address: ____________________________________________________________________________________
Rev. March 2017
STATE OF CONNECTICUT
INSURA N CE DEPARTMENT
Consumer Affairs Division
P.O. Box 816 – Hartford CT 06142‐0816
PHONE 860.297.3900 | FAX 860.297.3872
EMAIL insurance@ct.gov | WEBSITE www.ct.gov/cid
CONSUMER COMPLAINT FORM
Complainant Name: __________________________________________________________________________
Street: ______________________________________________________________________________________
City:
______________________________________ State: __________________ Zip Code: ____________
Daytime Phone: ______________________
Email: ________________________________________________
Relationship to Insured/Claimant: _______________________________________________________________
Name of Insured/Claimant
: ___________________________________________________
(If different than above)
Street: ______________________________________________________________________________________
City:
______________________________________ State: __________________ Zip Code: ____________
Type of Insurance:
Auto
Home/Renters
Life
Annuity
Commercial
Travel
Pet
Individual Health
Group Health - Employer Name: ___________________________
Disability
Dental
Long Term Care
Other ___________________________
Name of Insurance Company: ___________________________________________________________________
Policy # / Subscriber ID#:
___________________________________________________________________
If this complaint is related to a claims delay or claims denial:
Property & Casualty Complaints: Date of Loss: ____________________ Claim #: ______________________
Health or Dental Complaints:
Date(s) of Service: ______________________________________________
Name of Healthcare Provider: _____________________________________
Name of Agent/Agency
: ______________________________________________________________
(If applicable)
Address: ____________________________________________________________________________________
Rev. March 2017
S T A T E O F C O N N E C T I C U T
I N S U R A N C E D E P A R T M E N T
Consumer Affairs Division
P.O. Box 816 – Hartford CT 06142-0816
PHONE 860.297.3900 | FAX 860.297.3872
EMAIL insurance@ct.gov | WEBSITE www.ct.gov/cid
Please enter a description of your complaint in the space provided below. You may also attach
documents pertinent to your complaint to this form.
Please do not send originals.
I have enclosed copies of correspondence and documents relating to this matter to assist your investigation of the
complaint. I understand that copies of this form and any of the enclosed documents which may contain insurance and
health information may be forward to the insurance company and/or agent involved as deemed necessary by the
Connecticut Insurance Department to complete your investigation, and to any other state or federal agency that may be
able to assist you.
Signature of Complainant:
Date:
Rev. March 2017
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