GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING, INSURANCE AND FINANCIAL REGULATION COMPLAINT FORM Page 1 COMPLAINANT: Name: ________________________________________________________________________ Mailing Address: ________________________________________________________________ Telephone No.: (_____) _________________ (Home) (_____)_______________(Work) (_____) _________________ (Other) STATUS OF COMPLAINANT: ❑INSURED ❑THIRD PARTY ❑BENEFICIARY ❑BROKER ❑AGENT ❑OTHER COMPLAINT AGAINST: ❑AGENT ❑BROKER ❑CONSULTANT ❑ADJUSTER ❑INSURANCE COMPANY ❑OTHER Indicate Individual’s/Company’s Name: _____________________________________________ Telephone No.: (_____) ___________________ Facsimile No.: (____) __________________ TYPE OF COVERAGE: ❑AUTOMOBILE ❑HOMEOWNERS ❑LIFE ❑COMMERCIAL MUTI PERIL ❑OTHER REASON FOR COMPLAINT: ❑ PREMIUM RATES ❑ REFUSAL TO INSURE ❑ TWISTING ❑ CANCELLATION / RENEWAL ❑ AGENT HANDLING ❑ MISLEADING ADVERTISING ❑ DENIAL OF CLAIM ❑ CLAIM HANDLING DELAYS ❑UNSATISFACTORY SETTLEMENT ❑ MISREPRESENTATION ❑ SERVICE ❑ OTHER: ____________ Complaint No.__________ Date Received: __________ Date Resolved: __________ 5049 Kongens Gade, 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 Page 2 SUMMARY / REASON FOR COMPLAINT: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___________________________ _________________________ Signature Date EXAMINER’S FINDINGS: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _________________________ _______________________ Signature Date Hearing Requested By: __________________ Hearing Date: _________________ Notice of Penalty: ___________________ Penalty Imposed: _________________ Court Action: _______________________ Date: __________________________