"Pre-need Complaint Questionnaire" - Nebraska

Pre-need Complaint Questionnaire is a legal document that was released by the Nebraska Department of Insurance - a government authority operating within Nebraska.

Form Details:

  • The latest edition currently provided by the Nebraska Department of Insurance;
  • 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 printable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Insurance.

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Download "Pre-need Complaint Questionnaire" - Nebraska

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PRE-NEED DIVISION
COMPLAINT QUESTIONNAIRE
Complaint was made by: _________________________________________________
(Please print your name)
Complainant’s Address: __________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
Home Telephone Number: ________________ Work Telephone: ________________
Complaint is directed against: _____________________________________________
(Pre-Need Establishment’s Name)
Trustee for the Pre-Need Trust: ____________________________________________
(Financial Establishment holding the Pre-Need trust)
Pre-Need Agreement Date: __________ Pre-Need Trust Type: __________________
(Irrevocable/Revocable)
Total Agreement Amount: ___________ Total amount paid to Seller: ______________
Summary of Complaint: ________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
(An additional page may be used if necessary)
Date: ______________
Signature: _______________________________________
Nebraska Department of Insurance
PO Box 82089
Lincoln, NE 68501
PRE-NEED DIVISION
COMPLAINT QUESTIONNAIRE
Complaint was made by: _________________________________________________
(Please print your name)
Complainant’s Address: __________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
Home Telephone Number: ________________ Work Telephone: ________________
Complaint is directed against: _____________________________________________
(Pre-Need Establishment’s Name)
Trustee for the Pre-Need Trust: ____________________________________________
(Financial Establishment holding the Pre-Need trust)
Pre-Need Agreement Date: __________ Pre-Need Trust Type: __________________
(Irrevocable/Revocable)
Total Agreement Amount: ___________ Total amount paid to Seller: ______________
Summary of Complaint: ________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
(An additional page may be used if necessary)
Date: ______________
Signature: _______________________________________
Nebraska Department of Insurance
PO Box 82089
Lincoln, NE 68501