Effective January 21, 2013
State Of California
Department of Insurance
Authorization and Designation of Agent
• If you want to give someone the authority to assist you in the filing of your complaint please fill in Parts A
and B below.
• If you are a parent or legal guardian filing this complaint for a child under the age of 18, you do not need to
complete this form.
• If you are filing a complaint for a consumer who cannot complete this form and you have legal authority to
act for this consumer, please complete Part B only. Also send a copy of the power of attorney for health
care decisions or other legal document that says you can make decisions for the consumer.
PART A: COMPLAINANT
I allow the person named below in Part B to assist me in completing a complaint filed with the California
Department of Insurance (CDI). I allow the CDI to share my personal information with the person named
below in Part B. This may include information about my medical condition(s) and care if applicable and may
include mental health treatment, HIV treatment or testing, alcohol or drug treatment, or other health care
information.
I understand that only information related to my complaint will be shared.
My approval of this assistance is voluntary and I have the right to end it. If I want it to end, I must do so in
writing.
Name of Complainant (Print) ________________________________________________
Complainant Signature__________________________________ Date_______________
PART B: PERSON ASSISTING THE COMPLAINANT
If Applicable, Name of Organization (Please print)
__________________________________________________________
Name of Person Assisting (Please print)
__________________________________________________________
Signature of Person Assisting _______________________________________________________
Address ________________________________________________________________________
Relationship to Complainant
_______________________________________________________________________________
Daytime Phone # _________________________ Evening Phone # _______________________
My Power of Attorney for health care decisions or other legal document is attached.
Return the completed form to California Department of Insurance, Consumer Services Division, 300 S. Spring
Street, Los Angeles, CA 90013. If you have any questions, the Department can be reached at (800) 927-4357,
Outside of California (213) 897-8921.
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