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Friday, July 03, 2009

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Insurance Home » Consumers » Complaints

Insurance Consumer Complaint Form

This form is only for the use of Missouri residents and those with Missouri insurance policies. When you electronically submit it, the form will be sent to the Missouri Department of Insurance, Financial Institutions & Professional Registration.

Please complete all relevant items below. Some items must be filled in for the form to be submitted, and you will be asked to fill in those fields if you initially left them blank. You may be asked at a later time to provide correspondence and/or other papers that may help in the investigation of your complaint. A copy of this form and any or all subsequent information you provide will be sent to the party complained against.



* Required Field
*Select One:
I do not authorize the release of any of my file information, other than to the party complained against.
I authorize release of my name and address only to outside parties as requested.
I authorize release of my complaint form only to outside parties as requested.
I authorize release of any of my file information, including medical records, to outside parties as requested.
1. Complainant
* * :

Age of Insured:
1-24 25-49 50-64 65+
*E-mail Address:

If you do not have an E-mail address, please check this box.
*Street Address:
* * *
*Home Telephone Number: (e.g., (573) 555-1212)
 Work Phone Number:
2. Insured
*Name (if same, write same):
 Employer name (if group policy) and policy number:
3. Who is the complaint against?
*EXACT Name of Company, Producer/Agent etc.:
Street Address:
City, State, Zip:
4. Group or certificate number:
 		*Policy or ID number:
 Effective date:
5. Claim number:
 		Agent name (if applicable):
 Date of Loss:
6. *Type of Insurance Involved (check one):
Bond Title Long Term Care Renters Disability
Individual Life Individual Health Private Auto Homeowners Workers Comp
Group Life Group Health Commercial Auto Mobile Homeowners Warranty
Annuity
Medicare Supplement (Specify Plan A through J):
Other (specify):
7. *Reason for Complaint (check one or more):
Claim problem Claim delay Sales problem
Premium problem Policy problem Other, please specify:

Details of my complaint: