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1 WEST VIRGINIA OFFICES OF THE INSURANCE COMMISSIONER CONSUMER COMPLAINT FORM Please be advised that any materials, medical records or docu ments that you provide at any time in connection with your ents against whom your complaint is filed, and their counsel. complaint will be shared with the insurance companies or ag These documents will also be distributed to ur contested case or other matter pending before the other parties engaged in yo Insurance Commissioner, including but not limited to hearing exam iners who may have to decide your issue(s), the Office of the Consumer Advocate, and other appropriate employees of th is agency. Documents other than those that are exempt under the West Virginia Freedom of Information Act may also be releas ed if we receive a request for the records under that Act. By ioner of West Virginia to Offices of the Insurance Commiss signing the complaint below, you are specifically authorizing the that you have filed at any time with t he disseminate or distribute to any party or entity described above any private information further authorize such other dist ribution of this information as Consumer Service Division that relates to your complaint. You the laws of the United States and the State of West Virginia permit or require. YOUR NAME: YOUR ADDRESS: YOUR TELEPHONE NUMBER: YOUR E-MAIL ADDRESS: CLAIMANT’S NAME(if other than yourself): INSURED’S NAME(if other than yourself): INSURANCE COMPANY AND/OR AGENT (complaint is against): OTHER INDIVIDUALS OR ENTITIES INVOLVED: DATE OF LOSS: TYPE OF COVERAGE(ex. Auto, homeowners, health, life): CLAIM NUMBER: POLICY NUMBER: SPECIFIC POLICY LANGUA GE IN QUESTION(if known): ESTION(if known): STATUTORY / RULE PROVISION(S) IN QU REASON FOR COMPLAINT / RELIEF REQUESTED: Please describe the facts and circumstances which form the basis of your complaint. You may attach additional pages if necessary. Please attach copies of any relevant correspondence, policy provisions, etc. A complaint filed on behalf of a corporation must be signed by an officer of the corporation. In order for this division to take any action on your complaint, you must sign and date this form, indicating your agreement to the following: I hereby authorize any insurance company, or their representative, to provide to the West Virginia Offices of the Insurance Commissioner any documents, claim-related data, or other information necessary for consideration of this complaint, including but not limited to any medical reco rds and/or private or personal information requested. Signature: Date: Please complete, sign and date, and return the original form and any attachments to: Phone: (304) 558-3386 Consumer Service Division Toll-free in WV 1-888-TRY-WVIC WV Offices of the Insurance Commissioner Post Office Box 50540 Fax: (304) 558-4965 Internet: www.wvinsurance.gov Charleston, West Virginia 25305-0540 IF YOU HAVE ANY QUESTIONS OR PROBLEMS COMPLETING TH IS FORM, PLEASE CALL OUR OFFICE AT 1-888-TRY-WVIC (1-888- 879-9842) AND WE WILL ASSIST YOU. Revised 1/08

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