Consumer Complaint Form: Instructions
Consumer Complaint Form: Instructions
Consumer Complaint Form: Instructions
Instructions:
• File a complaint with the insurer, institution, or individual in question before filing a complaint with DFS.
• Complete this form. Be as detailed as possible. Print very clearly and neatly in dark ink.
• Enclose or attach copies of all related documents concerning your transaction. Do not send originals!
About You
Name:
Street address:
Email Address:
Representative: If you are filing this on behalf of someone else, provide your name, business name,
address, phone, email address and your relationship to the person for whom you are filing.
Street address:
City / town:
Phone number:
Policy or account number(s) related to this complaint (if any):
About Your Complaint
What product best describes your complaint: (Insurance, Banking, Mortgage, Student Loan, check
cashing, etc.) (Add further details of your transaction or complaint to the area on page 2 where
indicated):
Account/Policy/Claim Number:
If this matter is regarding insurance is your policy being canceled? Yes: No:
Did you complain to the company?
Date of Response:
Company Response:
Please describe complaint in detail here (or enclose a letter describing the complaint):
To resolve your complaint, we may send a copy of this form to the person or firm you are complaining about.
READ THE FOLLOWING BEFORE SIGNING BELOW: In filling this complaint, I understand that the Department of
Financial Services is not my private attorney but represents the public in enforcing laws designed to protect the
public from misleading or unlawful business practices. I also understand that if I have any questions concerning
my legal rights or responsibilities, I should contact a private attorney. I have no objection to the contents of this
complaint being forwarded to the institution or person the complaint is directed against. The above complaint is
true and accurate to the best of my knowledge.
Signature: Date:
ATTACH OR ENCLOSE COPIES OF ANY DOCUMENTS THAT RELATE TO YOUR COMPLAINT (CONTRACTS, BILLS,
CANCELLED CHECKS, CORRESPONDENCE, ETC.) DO NOT SEND ORIGINALS.