STATE OF NEVADA OFFICE OF THE ATTORNEY GENERAL BUREAU OF CONSUMER PROTECTION 555 East Washington Avenue, Suite 3900 Las Vegas, Nevada 89101 100 North Carson Street, Carson City, Nevada 89701 NEVADA HEALTH INSURER COMPLAINT FORM INSTRUCTIONS: Complete this form to report a possible violation of law of any health insurer that does business in Nevada. Please type or print your complaint in ink and complete the form fully. Return your original, signed form with any attachments for processing to the most appropriate address above. Thank you for taking the time to complete this form. SECTION 1: Complainant Information Your Name: __________________________________________________________________________ Job Title (if any): __________________________________________________________________________ Company Name (if any): __________________________________________________________________________ Mailing Address: __________________________________________________________________________ City, State, and Zip: __________________________________________________________________________ Daytime Phone Number: __________________________________________________________________________ SECTION 2. Complaint Description Identify the health insurer(s) you are complaining about: ______________________________________________________________________________________________ If known, identify the law(s) (e.g. NRS ____, NAC _____) or something similar to a law (e.g. court order, settlement) you believe the health insurer(s) is/are violating: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Describe why you believe the health insurer(s) is/are violating the law, or similar conduct that is equally troubling. Give full details, e.g. the “who, what, when, where, and why” of your complaint. Use additional sheets, as is necessary. ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Nevada Health Insurer Complaint Form: Page 1 of 2 Rev: 5/09 American LegalNet, Inc. www.FormsWorkFlow.com ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ SECTION 3. Attachments List and attach photocopies (no originals) of any relevant documents (e.g. agreements, letters) that support your complaint. Use additional sheets, as is necessary. a _______________________________________________________________________________________ b. _______________________________________________________________________________________ c. _______________________________________________________________________________________ d. _______________________________________________________________________________________ e. _______________________________________________________________________________________ f. _______________________________________________________________________________________ g. _______________________________________________________________________________________ SECTION 4. Certification Sign and date this form. The Bureau of Consumer Protection can not process any unsigned, incomplete, or illegible complaints. I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that the information may contain confidential information and that the Bureau of Consumer Protection is not obligated to keep such information confidential, as it may be required to disclose the information in order to process the complaint (e.g. it may be referred to another government agency that has jurisdiction over the complaint) and/or pursue an investigation or enforcement action on behalf of the State of Nevada. I also understand that the Bureau of Consumer Protection is not my attorney, and can not provide me with any legal advice or representation. ___________________________________________ (Signature) ______________________________________________ (Print Name) Date: ______________________________________ Nevada Health Insurer Complaint Form: Page 2 of 2 Rev: 5/09 American LegalNet, Inc. www.FormsWorkFlow.com