Home, Auto, Life Insurance Complaint Form




The Consumer Assistance Bureau investigates complaints involving insurance companies, adjusters and other insurance industry staff members with regards to the issuance of policies and processing of claims. The Insurance Complaint Unit cannot act as your lawyer, provide legal advice, or recommend or rate insurance companies.


We are forbidden from determining liability, damages or making settlement decision on your behalf. You may wish to consult with a private attorney to explore what rights of action or other redress options you may have based on the circumstances of your particular case.


After submitting this form, a copy of your completed form will be sent to the insurance company, agent or adjuster in order to obtain a written response. Upon receipt of this response, the case will be reviewed and if necessary, further investigation will be conducted. You will be notified of the results.

* designates required field


If you prefer to download the complaint form, click here * designates required field
   
 Customer Contact Information (The name on your bill or account)
* Customer Name: * Phone Number:
* E-Mail Address: May we contact you by email?    Yes      No
 Are you represented by an attorney?    Yes    No Have you filed a lawsuit in Court ?    Yes    No
       
Street Address
* Street: * City:
* State: * Zip:
       
Insurance Company, Agent, or Adjuster of your Complaint
* Insurance Company Name: Policy Number:
Is this your insurance company? Yes No State of Purchase
Policy Issue or Effective Date: Current Servicing Agent's Name:
Sales Agent's Name:    
Type of Insurance: Life
Health
Auto
Home
HMO
Service Warranty
 
Claim No: Date Loss Occurred or Began:
Adjuster's Name: Adjuster's Phone:
       
Reason for Complaint
Claim Denial Delays
Policy Cancellation Premium Rate
Company Service Refusal to Insure Damage Amount Dispute Agent Service
Other:    
       
Statement of Facts

* Please provide a short (200 word) description of your complaint.

 

To provide a more detailed summary of your complaint,

please include it as an attachment, if required.

Email copies of any documents you believe will assist us.

Please submit relevant documentation such as copies of the bill(s) in dispute, cancelled checks, copy of your policy, receipts, etc.
If you prefer, you may send additional documentation via email: osi.consumer@state.nm.us or via fax: 505-827-4253
Explain what you feel would be a fair resolution of this matter.

(What do you think the company should
do to make this situation right?)
       
Supporting Documents

To submit relevant documentation such as copies of the bill(s) in dispute, cancelled checks, receipts, etc., please send these via email: osi.consumer@state.nm.us or via fax: 505-827-4253. Please reference your last name on the documentation sent.

The information provided on and with this form is true and correct to the best of my knowledge and belief. I am enclosing copies of any correspondence or other documentation in my possession that may be of assistance. I fully understand that a copy of this form and any or all of the enclosed information may be forward to the involved insurance company or agent. I also understand that the facts relating to this matter will become a matter of public record pursuant to New Mexico law once my filed is closed.

   

It is very important to make sure that we receive your submission properly.  When your form submission is completed correctly, you will receive a page with your form submission information.

If you do not receive this page, and instead encounter an error page, please read it carefully, go back on your browser, correct your submission, and resubmit. If you have any questions, whatsoever, please contact us here.