GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS 
OFFICE OF THE LIEUTENANT GOVERNOR 
DIVISION OF BANKING AND INSURANCE 
 
CONSUMER ASSISTANCE PROGRAM 
COMPLAINT FORM 
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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 
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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: 
 
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_________________________ 
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 
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EXAMINER’S FINDINGS: 
 
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Signature 
 
 
 
 
 
 
 
 
Date 
 
 
Hearing Requested By: __________________ Hearing Date: _________________ 
 
Notice of Penalty: ___________________   Penalty Imposed: _________________ 
 
Court Action: _______________________   Date: __________________________