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Indiana Department of Insurance

IDOI > Consumer Services > Complaints > Submit a Complaint Online Submit a Complaint Online

Please Complete the Entire Form.
 
Please do not include Social Security Numbers.

Your Contact Information






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Complaint Information
  1. (A) Type of Insurance (Please check one):











  2. My complaint is against:
    Name of Insurance Company:
  3. What State was your policy issued/purchased in:
  4. If an agent is involved, please give the agent's name and address:



  5. If group insurance, please give the name of the employer. 
  6. If a property loss or an accident is involved: 


I hereby authorize the release of confidential medical and/or other information to the Department of Insurance. I understand that medical records WILL NOT be public at any time.

Reminder: Please do not include Social Security Numbers.

Your complaint will be kept on file at the Department of Insurance and will become a public record. If you need to send us confidential information (for example, medical records), please send copies of your original documents to us by regular mail. The regular mail address is located here.