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Nebraska Department of  Insurance

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COMPLAINT FORMS



If you did not reside in Nebraska when you purchased the policy, please contact the state in which you resided at time of purchase. Click here for a map of Insurance Departments.

Based on the complaint information you wish to send to the Department, you may file your complaint electronically or by mail. If you do not wish to print a complaint form using the Adobe Acrobat Reader or you do not wish to submit your complaint electronically, you can contact the Department at 877-564-7323 and a complaint form will be sent to you for completion. For information on how to complete a Complaint Form, read our Filing An Insurance Complaint brochure.

WHICH COMPLAINT FORM SHOULD I USE?



If:
you have supporting documentation that will accompany your complaint, or

your complaint involves a health or injury claim requiring an original signature authorizing the release of your medical records to the Department of Insurance (Consumer Affairs Division Complaint Questionnaire only)

you must use one of the forms under the heading Printed and Mailed.

Once you have completed one of these forms, mail to:
MAILING ADDRESS
Nebraska Department of Insurance
PO Box 82089
Lincoln, NE 68501-2089
STREET ADDRESS (UPS/FedEx)
NE Department of Insurance
941 O Street, Suite 400
Lincoln, NE 68508



If you have no supporting documentation to accompany your complaint or your complaint does not involve a health or injury claim, please complete one of the forms under the heading Electronically Filed.

Printed and Mailed
Electronically Filed

Consumer Affairs Division Complaint Questionnaire

Use this form if you have a general complaint regarding an insurance company, agent, or the handling of your claim.
Division De Asuntos Del Consumidor Cuestionario De Quejas


Consumer Affairs Division Complaint Questionnaire

Use this form if you have a general complaint regarding an insurance company, agent, or the handling of your claim.
Pre-Need Complaint Questionnaire
Use this form if your complaint concerns the handling of a pre-need trust. A pre-need trust is the purchasing of burial or funeral merchandise (casket, vault, monument, etc.) or services prior to the time of death.

Pre-Need Complaint Questionnaire
Use this form if your complaint concerns the handling of a pre-need trust. A pre-need trust is the purchasing of burial or funeral merchandise (casket, vault, monument, etc.) or services prior to the time of death.

Suspected Fraudulent Claim Report
Use this form if you suspect insurance fraud. Examples of insurance fraud include 1) creating a fraudulent claim, 2) overstating the amount of loss, 3) misrepresenting facts to receive payment, 4) representing facts to obtain a policy or lower premiums, or 5) pocketing premiums, issuing bogus policies, or making false entries by an agent or insurer.
Prompt Pay Problem Report Form for Health Care Professionals
Nebraska health care providers may use this form to report insurer delays in payment of health claims submitted after January 1, 2006. Reports involving multiple claims submitted to a single insurer may be attached as a supplement and filed in paper format, but must include the plan type, the patient's name, the insured's or policyholder's name, the policy number, the claim number, the date of submission of the claim and a description of the problem for each individual claim. The Department of Insurance will not initiate an investigation based on the report form, but will record the information for monitoring purposes.