Fillable Insurance Complaint Form - Insurance Complaint Form for testing Adobe

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Insurance Complaint Form - Insurance Complaint Form for testing Adobe

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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CHARLES D. BAKER
GOVERNOR
KARYN E. POLITO
LIEUTENANT GOVERNOR
COMMONWEALTH OF MASSACHUSETTS
Office of Consumer Affairs and Business Regulation
DIVISION OF INSURANCE
1000 Washington Street • Suite 810 • Boston, MA 02118-6200
(617) 521-7794 • FAX (617) 753-6830 • Toll-free (877) 563-4467
http://www.mass.gov/doi•CSSComplaints@mass.go
v
MIKE KENNEALY
SECRETARY OF HOUSING
AND ECONOMIC
DEVELOPMENT
EDWARD PALLESCHI
UNDERSECRETARY OF CONSUMER AFFAIRS
AND BUSINESS REGULATION
GARY D. ANDERSON
COMMISSIONER OF INSURANCE
INSURANCECOMPLAINTFORM
Address:
City:
Phone#:
E‐mail:
Isthecomplaintaboutyourpolicy? No Yes
__________
Whom is the complaint against? Please provide the exact name of the company or

producer.
Please note, in order to process your complaint in a timely manner, please be sure to include the name of insurance
company, your policy number and claim numbers.
DateofLoss:
Bond
Life
Long‐TermCare
Renters
Annuity
Private Auto
TripCancellation
Nameofagency:
File#:
HaveyoureportedthistotheAttorneyGeneral’sOffice,theOffice of Consumer Affairs
and Business Regulation or any other government agency? No
Yes
If yes, please provide:
Policy/ID #:Group/certificate #(If Applicable):
Claim #:
State:
Mr.
Mrs.
Ms.
Zip:
_________________________________________________________________________________________________________
Before you file a complaint with the Massachusetts Division of Insurance, you should first contact the insurance
company or producer in an effort to resolve the issue(s). If you do not receive a satisfactory response, then
complete this form and attach copies of any important papers that relate to your complaint. Please mail or fax
your completed form to the address shown above. If your complaint involves ongoing litigation, DO NOT
complete this form.
Which state did you reside in at the time this policy was purchased?
Disability
Title
Workers Comp
Mobile Homeowners
Health
Homeowners
Medigap
Commercial Auto
Other
Type of Insurance (check one):
MA
MA
DETAILSOFYOURCOMPLAINT
I authorize the release of any information regarding this complaint. I acknowledge
that complaints and inquiries filed with the Division of Insurance are public
recordandmaybeavailableforreviewuponrequest.IauthorizetheDivision
of Insurance to send a copy of this complaint and related material to any company,
producer,orlicensee.IauthorizetheDivisionofInsurancetorefer
thiscomplainttoany
governmentagencywhendeemedappropriatebytheDivisionof
Insurance.
SIGNATURE: DATE:
By Entering my name below, I certify that: (required)
You may send additional complaint details and/or copies of important documents that relate to your
complaint to CSSComplaints@mass.gov.
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Completed 2 December 2019

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