Nebraska Department of Insurance

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If a health or injury claim is involved, the Department requires an original signature on the complaint form for the release of your medical records so our investigation can be done properly. Please return to the Complaint Forms page and follow the printing instructions.

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Complaint made by (Please provide your name, your mailing address, and your work and home phone numbers):

Last Name: First Name: MI:
Address:
City: State: Zip Code:
Home Phone Number: Work Phone Number:
E-Mail Address:

Please check age group:

<25 25-49 50-64 65+

Complaint is Directed Against: (Will generally be an Insurance Company or Producer)

Policy Type:

Life Health Auto Property Other (Please specify)

Policyholder: Policy #:

Agent: Adjuster:

If Claim, Claim #: If Claim, Date of Loss:

Summary of Complaint: (Please itemize and specifically discuss each problem)