File A Complaint

Before you file a request for assistance with the Alabama Department of Insurance, you should first contact the insurance company or producer in an effort to resolve the issue(s). If you do not receive a satisfactory response, then fill in this on-line form. Any important documentation that relates to your request for assistance should be mailed to:

Alabama Department of Insurance
P O Box 303351
Montgomery, AL 36130-3351

Click Here for the form in PDF format. You must have Adobe Acrobat Reader on your computer in order to view the 'PDF' form. Please click on the icon below to be taken to the Adobe web site to download Acrobat Reader for free.

First Name:


Last Name:


Address:


City:


State:


Zip Code:


Work Phone:
()-

Home Phone:
()-

Email Address:



Complete Name of Insurance Company as Shown on Your Insurance Policy:


Type of Insurance:
Life Health Medicare Supplement Auto Home Other

Type of Insurance (if other):


Name of Policyholder (if different from your name):


Group Name and Group Number (if a group policy):


Policy Identification or Certification Number:


Claim Number (if applicable):


Date Loss Occurred or Began (if applicable):


Agent (if applicable):


Agent's Phone Number:
()-

Have you contacted the company or agent?
YesNo
If yes, state the date(s) and person(s) contacted.


Have you reported this to any other governmental agency?
YesNo
If yes, please give the name of the agency and the file number, if known.


Have you previously written to the Alabama Department of Insurance about this matter?
YesNo 
If yes, please state the date(s) and person(s) contacted.


Is a lawsuit currently pending?
YesNo
Briefly, describe your problem below.