NEVADA STATE DIVISION OF INSURANCE
COMPLAINT FORM

This complaint form is for use by any person who has an insurance-related problem.  Attempts should first be made to resolve the problem with your own insurance company as most insurance companies have personnel specifically for dealing with complaints.  If the issue cannot be resolved with the insurance company, please complete and submit the below form.  The Nevada State Division of Insurance regulates fully-insured plans such as auto, home, life and health along with other lines of insurance.  We do not, however, regulate self-funded health plans.  For complaints on self-funded health plans, you can contact the United States Department of Labor at (866) 444-3272.  

Please submit all requested information

Today's Date*  

Please identify yourself:  PLEASE TYPE NAME AND ADDRESS IN CAPITAL LETTERS

First Name*:
Middle Initial:
Last Name*:
Address*:
City*:
State*:
Zip Code*:
.  

Where can we contact you?  YOU MUST INCLUDE THE AREA CODE FOR YOUR HOME PHONE NUMBER WHETHER OR NOT YOU ARE PROVIDING A HOME NUMBER.

Work Phone Area Code Phone No.
Home Phone Area Code*   Phone No.
FAX Area Code   Phone No.
E-mail

Tell us about your complaint:

REMEMBER, INSURANCE AGENT AND INSURANCE COMPANY ARE NOT THE SAME.

Is this a claim against a policy you purchased?     NV License Plate No.:
If no, whose policy are you making a claim under?
Specific Name of Insurance Company:
Policy No. (if known):   Claim No.
Date of loss/accident/illness:  
Agent's name (if known): Phone No.
Adjuster's name (if known): Phone No.

Please provide a brief summary of the information concerning your complaint.  

 

* Required Field

The Division of Insurance will be in contact with you regarding your complaint within three business days.

PLEASE CLICK ON THE "SUBMIT" BUTTON ONLY ONCE TO SUBMIT YOUR COMPLAINT.

Elena Williams
Copyright © 1999 [Division of Insurance]. All rights reserved.
Revised: May 28, 2008