New Mexico Insurance Fraud Bureau Agent Complaint or Commendation Form

Complete and submit the form below; your contact information is not required.

Name:
Address:
Phone (Work)
Phone (Home)
Date and Time of Incident:

Name of Agent(s) for whom complaint or commendation is being filed, or other identifying marks

Name:
ID#:
Vehicle:
Other:
Name(s) / Address / Phone Number or Other Identifying Information Concerning Witnesses:
Statement of Allegations:

I understand that this statement will be submitted to the New Mexico Insurance Fraud Bureau (NMIFB) and may be the basis for an investigation. Further, I sincerely and truly declare and affirm that the facts contained herein are complete, accurate, and true to the best of my knowledge and belief. Further, I declare and affirm that my statement has been made by me voluntarily, without persuasion, coercion, or promise of any kind. I understand that, under the regulations of the NMIFB, the Agent on whom a complaint is filed will be entitled to a hearing before a board of inquiry. I understand that I may be required to appear at the NMIFB for further interview(s) or provide other investigative assistance as necessary. By signing and filing this complaint, I hereby agree to appear before a board of inquiry, or grievance board, if one is requested by the Agent, and to testify under oath concerning all matters relevant to this complaint.

Signature
Date
Signature of Person Receiving Complaint or Commendation.
Date
 

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