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Insurance Complaint Form
Problem / Issue
Refusal to pay for procedures
Delay in processing supplement
Labor and/or Material rate
Consumer or Repair facility filing complaint
Adjuster phone number
Please describe the problem
Please indicate how you think your problem should be resoved.
Supporting documents PDF file
Please check the box to indicate that you consent to the following: The information I have given above is true and accurate to the best of my knowledge and belief. This information may be forwarded to the insurance company and/or agent involved. Any information which I have provided may be shared with the insurance company if necessary for the investigation of this matter.
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