INSURANCE COMPLAINT FORM TYPE OR PRINT CLEARLY WITH

125 South Webster Street

P.O. Box 7873

Madison, WI 53707-7873

oci.wi.gov

INSURANCE COMPLAINT FORM

The Office of the Commissioner of Insurance (OCI) assists consumers with their insurance problems. In order for us to investigate

your complaint, please complete this form as thoroughly as you can. Mailing details are available on the last page of this form. A

copy of your complaint will be sent to the company or agent with a request to respond directly to you and to advise our office of the

action taken. You should hear from the company or agent in about 25 days from the date you send us your complaint. When we

receive the information from the company or agent, we will review the file to determine what action we can take. We will notify you

of our determination. If our office is unable to obtain the resolution you desired, you may consider contacting a private attorney for

advice. If your complaint involved a claim dispute, you may want to contact your county's small claims court.

TYPE OR PRINT CLEARLY WITH A BLACK PEN. COMPLETE BOTH SIDES OF THIS FORM.

1. Your Name

Mailing Address

City State Zip Code

Email Address

(initial correspondence from OCI will be sent via email)

Phone number where we can reach you between 8 a.m.- 4:30 p.m.

2. Name of Insurance Company Involved

(Please provide the PRECISE NAME of the insurance company. Incorrect names will delay the handling

of your complaint. The name of the company can be found on your insurance policy, usually on the

first page.)

3. I am filing this complaint as:

Insured Agent Third-Party

Provider Other (specify)

4. Type of Insurance

Auto Individual Acc/Health Business Life Annuity

Home Group Acc/Health Other (specify)

5. Name of Insurance Agent and/or Agency Who Sold the Insurance and Their Address (Not the same as 2., above)

Agent Name Agency Name

Address

6. Name and Address of Public Adjuster/Public Adjusting Firm (Not the same as 2., above and not the insurer’s adjuster)

Public Adjuster Name Public Adjusting Firm

Address

7. Name of Policyholder (if other than 1., above) 8. Policy or Certificate #

9. Date Policy or Certificate Was Sold

10. State in Which Policy or Certificate Was Sold

11. Claim or File #, If Applicable 12. Date Loss Occurred or Began, If Applicable

OCI 51-005 (R 7/2021)

(OVER)

Complaint Phone Numbers

(608) 266-0103

(Madison)

(800) 236-8517

(Statewide)

(608) 264-8115

(Fax)

14. Please indicate how you think your problem should be resolved.

15. Have you previously reported this problem to us or any other governmental agency?

Yes

No If yes, state which agency and what action was taken?

Consent to Release Information

The information I have given above is true and accurate to the best of my knowledge and belief. This information may be forwarded

to the insurance company and/or agent involved. Any medical information which I have provided, may be shared with the insurance

company, if necessary, for the investigation of this matter. I understand that under Wisconsin's Open Records Law all information

which is in my file, including personal and health information, may become a public record once my file is closed. Only actual medical

records which are obtained from a health care provider are confidential under s. 146.82, Wis. Stat.

Signature

Date

Submission Details

If you would like to email, fax, or mail the form instead of submitting it online, please use the contact information below. If you have

questions or problems, call us toll-free at 1-800-236-8517 (within Wisconsin) or 1-608-266-0103 (outside of Wisconsin) or send an e-

mail to us at ocicomplaints@wisconsin.gov.

Email: ocicomplaints@wisconsin.gov

Fax: (608) 264-8115

Mail:

Office of the Commissioner of Insurance

P.O. Box 7873

Madison, WI 53707-7873

If you are sending your complaint by FedEx, UPS, Overnight Mail, etc., please

use our physical address:

Office of the Commissioner of Insurance

125 South Webster Street

Madison, WI 53703-3474

OCI 51-005 (R 7/2021)