"Consumer Complaint Form" - Kansas

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

Form Details:

  • The latest edition currently provided by the Kansas Insurance Department;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

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Consumer Complaint Form
Print and complete this form if you plan to scan, fax or email your complaint to our office. If you would like to submit your
complaint online directly to our office, visit www.ksinsurance.org.
*
Required field
*
Name:
*
Address:
*
City:
*
*
*
State:
ZIP:
Phone Number:
*
*
County:
Email:
*
If we need to contact you, what is your:
Preferred mode of contact (choose one):
Preferred time:
A.M.
Department hours:
M-F 8 a.m. to 5 p.m.
Phone
Email
Mail
P.M.
*
Who is the complaint against? Provide the name of the one or more of the following:
Name of Insurance Company:
Name of Insurance Agent/Agency:
Name of Insurance Adjuster or Appraiser:
Name of Insured:
Policy Number:
Claim Number:
Date and Location of Loss:
Amount Disputed:
*
Type of Insurance (choose one):
Annuity
Disability
Life
Title
Auto
Group Health
Long-Term Care
Workers
Compensation
Commercial
Home
Medicare Supplement
Other:
Dental
Individual Health
Renters
*
Reason for Complaint (choose one):
Agent Handling
Delays/No Response
Premium & Rating
Unsatisfactory
Settlement/Offer
Cancellation
Information Requested
Premium Notice/
Billing
Other:
Claim Delay
Misrepresentation
Premium Refund
Claim Denial
Non-renewal
ADDITIONAL INFORMATION IS REQUIRED
ON THE BACK SIDE OF THIS FORM
Consumer Complaint Form
Print and complete this form if you plan to scan, fax or email your complaint to our office. If you would like to submit your
complaint online directly to our office, visit www.ksinsurance.org.
*
Required field
*
Name:
*
Address:
*
City:
*
*
*
State:
ZIP:
Phone Number:
*
*
County:
Email:
*
If we need to contact you, what is your:
Preferred mode of contact (choose one):
Preferred time:
A.M.
Department hours:
M-F 8 a.m. to 5 p.m.
Phone
Email
Mail
P.M.
*
Who is the complaint against? Provide the name of the one or more of the following:
Name of Insurance Company:
Name of Insurance Agent/Agency:
Name of Insurance Adjuster or Appraiser:
Name of Insured:
Policy Number:
Claim Number:
Date and Location of Loss:
Amount Disputed:
*
Type of Insurance (choose one):
Annuity
Disability
Life
Title
Auto
Group Health
Long-Term Care
Workers
Compensation
Commercial
Home
Medicare Supplement
Other:
Dental
Individual Health
Renters
*
Reason for Complaint (choose one):
Agent Handling
Delays/No Response
Premium & Rating
Unsatisfactory
Settlement/Offer
Cancellation
Information Requested
Premium Notice/
Billing
Other:
Claim Delay
Misrepresentation
Premium Refund
Claim Denial
Non-renewal
ADDITIONAL INFORMATION IS REQUIRED
ON THE BACK SIDE OF THIS FORM
Notes:
What is your desired outcome?:
Attach any supporting
Kansas Insurance Department:
documentation relating
Attn: Consumer Assistance Division
When you have completed
to your complaint review.
Fax: 785-296-5806
this form, send it to:
1300 SW Arrowhead Rd.
Keep original copies.
Topeka, KS 66604
Email: kid.webcomplaints@ks.gov
Authorization
The Insurance Commissioner is authorized to send a copy of this complaint and any follow-up documents to any insurance company or agent/agency in
order to investigate my concerns. I authorize the release of all relevant information, including medical records, to the Insurance Commissioner’s office
cannot provide legal advice, I further understand and agree that the contents herein may be forwarded to other appropriate state or federal agencies, as
well as become accessible to others under the Kansas Open Records Act. Finally, I declare and verify under penalty of perjury and the laws of Kansas
that all of the above information is true and correct to the best of my knowledge.
*
Signature:
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