Form INS6012 "Enforcement Division Complaint Form" - Ohio

What Is Form INS6012?

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

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the Ohio Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form INS6012 by clicking the link below or browse more documents and templates provided by the Ohio Department of Insurance.

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Download Form INS6012 "Enforcement Division Complaint Form" - Ohio

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Enforcement Division
Ohio Department of Insurance
50 W. Town St., 3rd Fl.
Mike DeWine – Governor
Suite 300
Jillian Froment – Director
Columbus, OH 43215
(614) 644-2658
Enforcement Division Complaint Form
Fax (614) 387-0092
www.insurance.ohio.gov
Suspect / Agent
Name (First MI Last)
Telephone
Address
Date of Birth
City, State, Zip
Social Security
Type of Claim
Date of Loss
Synopsis
What is your loss?
Where did your loss occur?
When did your loss occur?
Are there any witnesses or other victims?
Yes
No
Who
If there is a violation, would you be willing to testify at a department hearing or criminal proceedings?
Yes
No
Your Information
Name (First MI Last)
Telephone
Address
E-mail
City, State, Zip
Signature
Accredited by the National Association of Insurance Commissioners (NAIC)
Page 1 of 1
INS6012 (Rev. 01/2019)
Enforcement Division
Ohio Department of Insurance
50 W. Town St., 3rd Fl.
Mike DeWine – Governor
Suite 300
Jillian Froment – Director
Columbus, OH 43215
(614) 644-2658
Enforcement Division Complaint Form
Fax (614) 387-0092
www.insurance.ohio.gov
Suspect / Agent
Name (First MI Last)
Telephone
Address
Date of Birth
City, State, Zip
Social Security
Type of Claim
Date of Loss
Synopsis
What is your loss?
Where did your loss occur?
When did your loss occur?
Are there any witnesses or other victims?
Yes
No
Who
If there is a violation, would you be willing to testify at a department hearing or criminal proceedings?
Yes
No
Your Information
Name (First MI Last)
Telephone
Address
E-mail
City, State, Zip
Signature
Accredited by the National Association of Insurance Commissioners (NAIC)
Page 1 of 1
INS6012 (Rev. 01/2019)