North Carolina Department of Insurance, Wayne Goodwin Commissioner
 
Services for Consumers
CONSUMER COMPLAINT FORM
 
  • What We Can and Cannot Do...
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    • Please be sure to include your policy number or subscriber i.d. number, if your complaint involves your policy or coverage.

    • If you DO NOT wish to include supporting documents, then please complete this form, and then click "Submit" to electronically send your complaint to the Department of Insurance.

    • If you DO wish to include supporting documents, then please do not submit this form electronically; instead, please complete and print the form, and mail it with supporting documents attached, to the North Carolina Department of Insurance, 1201 Mail Service Center, Raleigh, NC 27699-1201.

    • HEALTH CARE PROVIDERS: Do not use this form to file complaints regarding your patients' healthcare plans/claims. Please use the Provider Complaint Form that can be accessed from the Health Care Professionals and Facilities page.
     
    Symbol  indicates that the field is required.
     
    Consumer Information:
     Prefix:  
     First Name:  
     Last Name:  
     Business:
    (if applicable)    		  
     Address 1:  
    Address 2:  
     City:    State:   Zip: 
    County:  
    Work Phone:   Extension: 
    Home Phone:  
    Email Address:  
     
    Insurance Information:
     Name of Insured:  
     Insurance Company:  
    Agent:  
    Adjuster:  
    Policy or Subscriber I.D. Number:  
    Claim or Certificate Number:  
    Date of Loss(mm/dd/yy):  
     Type of Insurance(Please Select one)
      Life  Health  Auto 
      Homeowners  Other Life/Health  Other Property/Casualty 
    If Life or Health policy, show the state in which  
    your policy/cerificate was purchased:  
     Are you represented by an attorney in this matter? No  Yes 
    (If yes, please provide the consent form)    
    Attorney Name:  
     
     Details of Complaint:
     
    The Insurance Department is authorized to send a copy of this document(s) to any company or agency involved. I authorize the release of all relevant information to the North Carolina Department of Insurance for its use in the review of this matter. Please note that consumer complaints become public records in accordance with North Carolina General Statute 58-2-100.
     
     Date(mm/dd/yy):