FIS 2275 (2/18) Department of Insurance and Financial Services Page 1 of 1
Examination Experience Complaint
Name
Email Address
Address
City
State
ZIP Code
Daytime Phone Number
Alternate Phone Number
Examination Site
Date of Examination
Examination Type
Life Producer
Life Counselor
Accident & Health Producer
Accident & Health Counselor
Property Producer/Solicitor
Casualty Producer/Solicitor
Property & Casualty Producer/Solicitor
Property & Casualty Counselor
Personal Lines Producer
Life, Accident & Health Producer
Life, Variable Life & Annuities Producer
Public Adjuster
Independent Adjuster without Worker’s Comp
Independent Adjuster with Worker’s Comp
Surplus Lines Producer
Limited Lines Property & Casualty Producer
Surety & Fidelity Producer/Solicitor
Title Insurance Producer
Credit Insurance Producer
Variable Life & Annuities Producer
Please list events in the order they occurred. Briefly list all the specific items that form the basis of your complaint. If necessary,
attach additional pages to clearly document the events that occurred.
Details of Complaint:
Desired Outcome:
Signature:
Please submit completed form:
By mail to:
DIFS Licensing
PO Box 30220
Lansing, MI 48909-7720
Or by fax to:
(517) 284-8836
Or email to:
DIFS-Licensing@michigan.gov
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