GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS
GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE CONSUMER ASSISTANCE PROGRAM COMPLAINT FORM COMPLAINANT: Insured/Provider: ______________________________________________________ Mailing Address: ______________________________________________________ Telephone No.: (_____) ______________ (Home) (_____)_______________(Work) (_____) _______________(Other) E-Mail:_________________________ Gender: ❑Male ❑ Female Date of Birth (mm/dd/yyyy): ______________________ Language: ❑ English ❑ Spanish ❑ Other ____________ Status: ❑ Insured ❑Uninsured Insurer: ________________________________ Policy Number: ______________ STATUS OF COMPLAINANT: ❑ INSURED ❑PROVIDER ❑EMPLOYER ❑BROKER ❑AGENT ❑OTHER COMPLAINT AGAINST: ❑AGENT ❑BROKER ❑PROVIDER ❑EMPLOYER/ADMINISTRATOR X INSURANCE COMPANY ❑OTHER Indicate Individual’s/Company’s Name: __________________________________________ Address: ___________________________________________________________________ Telephone No.: _____________________ Facsimile No.: __________________ E-Mail: _____________ …
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GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE CONSUMER ASSISTANCE PROGRAM COMPLAINT FORM COMPLAINANT: Insured/Provider: ______________________________________________________ Mailing Address: ______________________________________________________ Telephone No.: (_____) ______________ (Home) (_____)_______________(Work) (_____) _______________(Other) E-Mail:_________________________ Gender: ❑Male ❑ Female Date of Birth (mm/dd/yyyy): ______________________ Language: ❑ English ❑ Spanish ❑ Other ____________ Status: ❑ Insured ❑Uninsured Insurer: ________________________________ Policy Number: ______________ STATUS OF COMPLAINANT: ❑ INSURED ❑PROVIDER ❑EMPLOYER ❑BROKER ❑AGENT ❑OTHER COMPLAINT AGAINST: ❑AGENT ❑BROKER ❑PROVIDER ❑EMPLOYER/ADMINISTRATOR X INSURANCE COMPANY ❑OTHER Indicate Individual’s/Company’s Name: __________________________________________ Address: ___________________________________________________________________ Telephone No.: _____________________ Facsimile No.: __________________ E-Mail: ________________________________________________ Complaint No.: ________________ Date Opened: _________________ Date Resolved/Closed: _______________ Kongens Gade No. 5049, Charlotte Amalie, St. Thomas VI 00802 Tel: (340) 774-7166 Fax: (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 Tel: (340) 773-6459 Fax: (340) 719-3801 TYPE OF COVERAGE: ❑AUTOMOBILE BODILY INJURY ❑INDIVIDUAL HEALTH ❑GROUP HEALTH ❑OTHER _____________ REASON FOR COMPLAINT: ❑ PREMIUM RATES ❑ REFUSAL TO INSURE ❑ ACCESS/COVERAGE ❑ CANCELLATION/RENEWAL/RECISSION ❑ AGENT HANDLING ❑ REIMBURSEMENT CHALLENGES ❑CARE IS EXPIREMENTAL/INVESTIGATIONAL ❑ MISLEADING ADVERTISING ❑ DENIAL OF CLAIM/NON PAYMENT ❑ CLAIM HANDLING DELAYS ❑UNSATISFACTORY SETTLEMENT ❑ PREEXISTING CONDITION ❑ NOT ELIGIBLE FOR HEALTH PLAN/BENEFITS ❑CARE IS NOT MEDICALLY NECESSARY ❑QUALITY OF SERVICE ❑ MISREPRESENTATION ❑ OTHER: _______________ SUMMARY / REASON FOR COMPLAINT: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___________________________ _________________________ Signature Date Kongens Gade No. 5049, Charlotte Amalie, St. Thomas VI 00802 Tel: (340) 774-7166 Fax: (340) 774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 Tel: (340) 773-6459 Fax: (340) 719-3801 EXAMINER’S FINDINGS: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _________________________ _______________________ Signature Date Hearing Requested By: __________________ Hearing Date: _________________ Notice of Penalty: ___________________ Penalty Imposed: _________________ Court Action: _______________________ Date: __________________________