INSTRUCTIONS: CONNECTICUT CONSUMER COMPLAINT FORM

To file a complaint regarding denial of insurance coverage in Connecticut, use the form discussed in this article. This document can be obtained from the website of the government of Connecticut.

Connecticut Consumer Complaint Form Step 1: Enter your name in the first blank box.

Connecticut Consumer Complaint Form Step 2: Enter your street address in the second blank box, your city in the third blank box, your state in the fourth blank box, and the zip code in the fifth blank box.

Connecticut Consumer Complaint Form Step 3: Enter your home phone number in the sixth blank box, your business phone number in the seventh blank box, your cell phone number in the eighth blank box and your fax number in the ninth blank box.

Connecticut Consumer Complaint Form Step 4: Enter your email address in the tenth blank box.

Connecticut Consumer Complaint Form Step 5: Section 1 should be completed if the complaint concerns your insurance coverage or policy. In section a, enter the name of your insurance company, as well as its street address, city, state and zip code.

Connecticut Consumer Complaint Form Step 6: In section b, enter the name of your agent or broker and their agency or other affiliation.

Connecticut Consumer Complaint Form Step 7: If the insured is not you, enter their name, street address, city, state and zip code. Write your relationship to the insured.

Connecticut Consumer Complaint Form Step 8: Enter your claim number, date of loss, the date you submitted your claim and the amount of the claim in section 2a.

Connecticut Consumer Complaint Form Step 9: In section 2b, enter your policy number, the policy cancellation date and the policy expiration date.

Connecticut Consumer Complaint Form Step 10: In section 2c, enter the date of notice of nonrenewal.

Connecticut Consumer Complaint Form Step 11: Enter the effective date of coverage in section 2d and the premiums paid in section 2e.

Connecticut Consumer Complaint Form Step 12: If the complaint concerns another person, enter all information requested about them in section 3.

Connecticut Consumer Complaint Form Step 13: Explain your complaint fully in section 4.

Connecticut Consumer Complaint Form Step 14: Enter your signature and the date at the bottom of the second page.

Connecticut Consumer Complaint Form Step 15: Mail this form to the address given at the bottom of the page.