Ohio Department of Insurance Consumer Services

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 Online Consumer Complaint Form
Complete all required fields below. Required fields are marked with an *.
     Consumer Information
*First Name    
*Last Name  
Middle Initial  
*Address 1    
Address 2  
  *City   *State *Zip    
*County   (Required for Ohio only)
Day Phone  (Format-9999999999)
Email Address  
     Small Business Owners
Name of Business  
Are You a Small Business Employer?          
 
     Insurance Information
*Select Company
Type Company Name  Here  if Not Listed above
Insured's Name
Agent Name  
Co/Agent Address 1
Co/Agent Address 2  
Policy or ID Number
(If your ID is your Social Security Number, give only the last four digits)		  
Group or Employer Name  
Claim Number  
Service/Accident Date  
Location of Accident  
Agent/Broker Name  
City   State     Zip  
*Type of Insurance  
*Type of Problem  
 
 
    *Describe Your Complaint  
 
  *How do you like to see your complaint resolved?  
 
 
  Please Note: This complaint form, all documents you send us, and any document received by our office as a result of handling your complaint may be a public record, subject to Ohio’s Public Records Act. This law requires all public records to be available for inspection by anyone, upon request. WARNING: All documentation we receive will be imaged, then destroyed. Make copies of your documents and send the copies to us. Do not send original records.
  To the best of my knowledge the above statement is correct. I understand that a copy of this form and any attachments may be sent to the insurance company or agent involved. I authorize the insurance company to release all of the medical records relating to this complaint to the Ohio Department of Insurance and I authorize the Ohio Department of Insurance to release medical records relating to this complaint to the insurance company or agent as necessary in order to resolve this complaint. I represent that I have the proper authority to execute this release.
   
  *