| If you prefer to download the complaint form, click here |
* designates required field |
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| Customer Contact Information (The name on your bill or account) |
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* Customer Name: |
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* Phone Number: |
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* E-Mail Address: |
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| Street Address |
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*Street: |
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* City: |
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* State: |
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* Zip: |
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| Reason for Complaint |
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Claim Denial |
Delays |
Policy Cancellation |
Company Service |
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Premium Rate |
Agent Service |
Refusal to Insure |
Other Insurance Company (Liability Claim) |
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| Insurance Company |
| * Name of Insurance Company: |
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Is this your insurer? |
Yes
No (Check one) |
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Insurance Carrier: |
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Policy Number: |
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| Policy Issue or Effective Date: |
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Carrier's Contact Name: |
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Sales Agent's Name: |
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State of Purchase: |
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Claim Number: |
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| Workers Comp Administration Policy Number: |
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Date Loss Occurred or Began: |
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| Adjuster's Name: |
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Adjuster's Phone Number: |
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| Statement of Facts |
* Explain
the details of your complaint.
Include copies of any documents you believe will assist us. |
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| Please submit relevant documentation such as copies of the bill(s) in dispute, cancelled checks, copy of your policy, receipts, etc. |
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| If you prefer, you may send additional documentation via email: leroy.aragon@state.nm.us |
Explain what you feel would be a fair resolution of this matter.
(What do you think the company should
do to make this situation right?) |
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| Supporting Documents |
The information provided on and with this form is true and correct to the best of my knowledge and belief. I am enclosing copies of any correspondence or other documentation in my possession that may be of assistance. I fully understand that a copy of this form and any or all of the enclosed information may be forward to the involved insurance company or agent. I also understand that the facts relating to this matter will become a matter of public record pursuant to New Mexico law once my filed is closed.
It is very important to make sure that
we receive your submission properly. When
your form submission is completed correctly,
you will receive a page with your form
submission information.
If you do not receive this page, and instead
encounter an error page, please read it carefully, go back on your browser, correct your submission, and resubmit. If you have any questions, whatsoever, please contact us here. |
