IDOI: Submit a Complaint Online

IDOI > Consumers > Complaints > Submit a Complaint Online Submit a Complaint Online

Please Complete the Entire Form.

Your Name:
Your Address:
Your City, State and Zip Code:
Daytime Telephone Number:	()

(A) Type of Insurance (Please check one):

	Automobile		Homeowners		Fire		Life
	Health		Medicare Supplement		Business		Other:

(B) If your complaint is about a Medicare Supplement policy, please give type of policy (A through J):

My complaint is against:
Name of Insurance Company:
Address of Insurance Company:

If an agent is involved, please give the agent's name and address:
Name:
Address:

Policy Number:
Claim Number (if known):

Name Insured:

If group insurance, please give the name of the employer.
Name:

If a property loss or an accident is involved:
Location and Date:
The name(s) of any other person involved (ex. other drivers):

Briefly describe your problem.

I hereby authorize the release of confidential medical and/or other information to the Department of Insurance. I understand that medical records WILL NOT be public at any time.

Your complaint will be kept on file at the Department of Insurance and will become a public record. If you need to send us confidential information (for example, medical records), please send copies of your original documents to us by regular mail. The regular mail address is at the top of this page.

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