WIND Umpire Review Board Complaint Form
Complaint Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Matter
Insurer
*
Insured
*
Claim Number
*
Policy Number
*
Date of Loss
*
-
Month
-
Day
Year
Date
Umpire's Name
*
First Name
Last Name
Umpire's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Umpire's Phone Number
Please enter a valid phone number.
Insured’s Appraiser
*
Insured’s Appraiser’s Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insured’s Appraiser’s Phone Number
Please enter a valid phone number.
Please state specifics of all ethical rules allegedly violated:
*
Please state specific facts and circumstances giving rise to the complaint against the Umpire:
*
Submit
Should be Empty: