Online complaint form

Use this form to submit a complaint about an insurance company.

We will do our best to advocate on your behalf. In the meantime, you should continue to pursue your rights under the terms of your insurance contract.

IMPORTANT: If the complaint involves medical issues, you must use the printable form and sign the medical release on the form.

* Indicates required field

Step 1. Your contact information
*Name
(First and last name)
*Address
*City
*State  *Zip Code
*Email
*Home Phone
(xxx-xxx-xxxx)
Work
(xxx-xxx-xxxx)
Cell
(xxx-xxx-xxxx)
Step 2. Policyholder contact information (if different than above)
Name of policyholder
(First and last name)
Address
City
State    Zip Code
Email
Home phone
(xxx-xxx-xxxx)
Work
(xxx-xxx-xxxx)
Cell
(xxx-xxx-xxxx)
Step 3. Insurance information
*Insurance Company
(Insurer you are filing the complaint against.)
Type of policy Group Individual Unknown
Policy#
Claim#
Date of loss/service
(mm/dd/yyyy)
*Type of Insurance
Other
(please provide description if not listed above)
Employer or
Plan Sponsor
Agent/Adjuster name
(Adjuster or insurance agent handling your account.)
Company name
Address
City
State  Zip Code:
Phone
(xxx-xxx-xxxx)

Step 4. Define your problem
Please check all that apply.
Claim denial Unsatisfactory claim settlement
Billing problem Premium increased
Claim delay Cancellation/non-renewal
Refusal to insure Misrepresentation
Poor service Other

*Give a brief explanation of the problem.
Step 5. Questions
*What do you want the insurance company to do?

If you send supporting documents via fax, U.S Mail, etc, please indicate that you filed a complaint online at the top of the first document. 

(Do not send original documents, copies only please.)

Email documents to: webcomplaintform@oic.wa.gov or
Mail to:PO Box 40256, Olympia WA 98504-0256 or
Fax to:(360) 586-2018
Step 6. Declaration
By filling in my name and date below, I declare the information contained on this form is true and accurate.

*Name
 (First and last name)
 *Date
(mm/dd/yyyy)
Step 7. How did you hear about us?
Please tell us how you heard of this office and the services provided.

Relative/Friend
Agent/Broker
Media/Publication
Internet
Other


Questions?

Call our Insurance Consumer Hotline at 1-800-562-6900.