Problem / Issue SteeringShort payRefusal to pay for proceduresDelay in processing supplementLabor and/or Material ratePhoto EstimatingOther

Consumer or Repair facility filing complaint ConsumerRepair Facility

Name *

Address *

State *

Zip *

Phone *

E-mail Address: *

Insurance company *

Claim number

Adjuster

Adjuster phone number

Please describe the problem

Please indicate how you think your problem should be resoved.

Supporting documents PDF file

Additional documents

Additional documents

Additional documents

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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