Fill - Free fillable (THIRD-PARTY CONSENT) CONSENT FOR THIRD PARTY TO FILE (Arizona) PDF form

FormC‐TPC(v.20200522

Consumer Services Section

ARIZONA DEPARTMENT OF INSURANCE

100 North 15th Ave. Suite 261

Phoenix, AZ 85007-2630

https://insurance.az.gov

CONSENT FOR THIRD PARTY TO FILE INSURANCE COMPLAINT

(“THIRD-PARTY CONSENT”)

I,theINSUREDORCLAIMANT,acknowledgethatIhavereadandunderstandtheSTATEMENT

providedbelowandthatIagreetohavemycomplaint

against

(insurancecompany,insuranceproducer/adjusterorother)

concerning(reason/summary of the complaint)

filedwiththeArizonaDepartmentofInsurance(ADOI)onmybehalfby

(“AUTHORIZEDPERSON”).

STATEMENT:Iunderstandthatthefactsrelatingtothiscomplaintwillbecomeamatterofpublic

record pursuant to Arizona law and that anyone may request and may have access to the

information related to my individual complaint. This THI

RD‐PARTY CONSENT expresses my

permissionfortheAUTHORIZEDPERSONtofilethecomplaint,respondtoADOIrequestsandact

onmybehalfwithrespecttothecomplaint.ThisTHIRD‐PARTYCONSENTautomaticallyexpires

upontheADOI’sclosureofthefiledcomplaintunlessIrevokeitinwritingatanearlierdate.

INSUREDORCLAIMANT

PrintedName Signature Date

__________________________________

StreetAddress City State ZIPCode

EmailAddress PhoneNumber

AUTHORIZEDPERSON

PrintedName Signature Date

__________________________________

StreetAddress City State ZIPCode

EmailAddress PhoneNumber

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(THIRD-PARTY CONSENT) CONSENT FOR THIRD PARTY TO FILE (Arizona)

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