Insurance Department Complaint Worksheet (Free PDF)
If your insurer won't respond or you believe your claim was handled unfairly, you can file a free complaint with your state insurance department. Fill this in first so the complaint is complete, dated and easy to follow.
Download the free PDF
Fillable on screen or printable · no email or sign-up · last reviewed 2026-09-29 by David Bennett
When to use it
- Your insurer stopped responding, missed deadlines, or denied or underpaid a claim without a clear reason.
- You've already asked the insurer in writing to fix it and haven't had a satisfactory answer.
What the form asks for
- Your name · Phone · Email
- Insurance company · Claim number · Policy number
- Date of loss · Date claim filed · Adjuster name
- Timeline of the claim (dates of each contact, offer and response)
- What you believe was handled unfairly or not answered
- What outcome you are asking for
- ☐ Your claim communication log
- ☐ Every letter and email from the insurer
- ☐ Valuation report or repair estimate
- ☐ Your written requests and any responses
How to fill it in
- Collect your claim communication log and every letter and email from the insurer.
- Write a dated timeline: each contact, offer and response.
- Describe what you believe was handled unfairly, then the specific outcome you want.
- Find your state's insurance department in the NAIC directory and file online or by mail, attaching the documents listed.
Frequently Asked Questions
Does it cost anything to file an insurance complaint?
No. State insurance departments take consumer complaints for free. They can require the insurer to respond, but they generally can't award damages or act as your lawyer.
What happens after I file a complaint?
The department usually forwards it to the insurer and asks for a written response, then reviews whether the insurer followed state law. Timelines vary by state. See our complaint guide for what a department can and can't do.
A template, not legal advice. Edit it to match your facts. For complex,
high-value or injury claims, consider a licensed attorney or independent appraiser in your
state. See the disclaimer.