• Insurance Notification Form

    Please fill out this form to submit a special notification regarding your insurance. Before you file a special notification with the Division of Insurance from your State, 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 notification. Please mail or fax your completed form to the address shown below.

  • Note:

    Please be sure to include all relevant information when you submit your complaint. If you need to send additional documents, please email them to proper authority (select a state below to find out the email).

  • If your complaint involves ongoing litigation, DO NOT complete this form.

  • I would like to file a complaint against {agentOParty} NPN {npn} because I did not authorize {agentOParty}NPN {npn} to initiate any application in the marketplace or to make any changes to my application on my behalf. My Agent of Record should be {typeA}, effective from {newEffective}

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  • I, {policyHolder}, understand that I can report this complaint in the State I reside using the information below:

  • ALABAMA: ConsumerServices@insurance.alabama.gov | PH: (334) 2414141 or (800) 4333966

  • ARIZONA: insurance.consumers@difi.az.gov | consumerinfo@azag.gov | PH: (602) 3642499

  • ARKANSAS: Insurance.Consumers@Arkansas.gov | PH: (800) 8525494 or (501) 3712640

  • DELAWARE: consumer@delaware.gov / PH:18002828611 or (302) 6747310

  • FLORIDA: Consumer.Services@myfloridacfo.com / PH: 18776935236 or (850) 4133089

  • GEORGIA: PH: 4046518600 or 18008691123

  • ILLINOIS: DOI.Complaints@illinois.gov / PH: 8664455364

  • INDIANA: mhiggins@idoi.in.gov or consumerservices@idoi.in.gov / PH: 8006224461 or 3172322395

  • KANSAS: KDOI.complaints@ks.gov / PH: 8004322484 or 7852963071

  • LOUISIANA: public@ldi.la.gov / PH: 18002595300 or (225) 3425900

  • MICHIGAN: DIFScomplaints@michigan.gov / PH: 8779996442

  • MISSISSIPPI: consumer@mid.ms.gov / PH: (800) 5622957 or (601) 3592453

  • MISSOURI: PH: 8007267390

  • NORTH CAROLINA: PH: 8554081212

  • NEBRASKA: doi.insurancecomplaints@nebraska.gov / PH: (877) 5647323 or (402) 4710888

  • NEW HAMPSHIRE: consumerservices@ins.nh.gov | PH: (603) 2712261 or (800) 8523416

  • OHIO: consumer.complaint@insurance.ohio.gov | PH: 8006861526

  • OKLAHOMA: ocre.complaints@oag.ok.gov | PH: (405) 5212991 or (800) 5220071

  • SOUTH CAROLINA: consumers@doi.sc.gov | PH: 8037376180 or 18007683467

  • TENNESSEE: cis.complaints@state.tn.us | PH: (800) 3424029 or (615) 7412218

  • TEXAS: ConsumerProtection@tdi.texas.gov | PH: (800) 2523439

  • By submitting this consumer complaint, I, {policyHolder}, certify that all the above information is true and correct to the best of my knowledge. I authorize the Division of Insurance of the State of {StateReside} to send a copy of this complaint and related material to any company, producer, or licensee to investigate my complaint, and/or to refer this complaint to any government agency as necessary. I acknowledge that complaint files are public record pursuant to {StateReside} law once the complaint file is closed and may be released upon request. The Division of Insurance of the State of {StateReside} will maintain the confidentiality of any personally identifiable information and personal health information to the extent required by law.

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