Louisiana Department of Insurance - Consumer Complaint Form

LOUISIANA
DEPARTMENTOF
INSURANCE

Consumer Complaint Form

Please fill in as much information as you can. indicates a required field.

1 General
2 Submitter
3 Insured
4 Insurance
5 Description
6 Resolution
7 Finish

General Complaint Information

Complaint is Against:

Complaint Against Name:

Type of Coverage:

Reason for Complaint:

Date of Loss (if applicable):

COVID19 Outbreak

This is a government-declared disaster-related complaint

Disaster Name:

Submitter's Information

Title (Mr./Ms./Mrs.):

First Name:

Middle Name:

Last Name:

Suffix:

Street:

City:

State:

Zip:

E-Mail:

I do not have an email address.

Home Phone:

Work Phone:

Cell Phone:

Emergency Phone:

Insured's Information

Title (Mr./Ms./Mrs.):

First Name:

Middle Name:

Last Name:

Suffix:

Organization Name:

Last 4 of SSN:

Date of Birth:

Age Group:

Street:

City:

State:

Zip:

E-Mail:

Home Phone:

Work Phone:

Cell Phone:

Emergency Phone:

Complaint Description

Please enter a description of the complaint below. Please provide as much information as possible including dates, names, provider information, dates of service and locations. You will have the opportunity to attach supporting files to your complaint once it is successfully submitted.

Fair Resolution

What do you consider to be a fair resolution to your problem?

You will have the opportunity to attach supporting files to your complaint once it is successfully submitted.

Submission

Please read the following statement:

To the best of my knowledge, the information contained herein is true and accurate. I understand that a copy of this form and any or all of the information attached may be sent to the party complained against.

By checking this box, you are providing your electronic signature and agreeing to the statement above.

Date: 11/21/2024

Consumer Complaint Form

Please fill in as much information as you can. indicates a required field.

General Complaint Information

Submitter's Information

Insured's Information

Insurance Information

Complaint Description

Fair Resolution

Submission

Please read the following statement:

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