DEPARTMENT OF INSURANCE
Complaint Form
Fields marked with an asterisk (*) are required.
PLEASE NOTE : In order to assist you, we need a detailed summary of the problem from your perspective, in addition to the information below. Upon successful completion of the online complaint form a tracking number will be assigned. This tracking number may be used as a reference number.
If you are filing a complaint on behalf of someone else you will need to complete third party authorization form. You may upload copies of the original documents.
Type of Insurance
If Other (please specify)
*Are you filing a complaint on behalf of someone else?
*Is the insured deceased?
One of the following is required:
  1. Executor/Executrix papers
  2. Proof that you are the Beneficiary
Please include the Tracking Number on your documents. You may fax to 502-564-6090 or mail to Consumer Protection Division, P O Box 517, Frankfort, KY 40602.
*Is that person 18 or older?
One of the following is required:
  1. Third Party Authorization
  2. Power of Attorney Papers
  3. Guardianship Papers
Please include the Tracking Number on your documents. You may fax to 502-564-6090 or mail to Consumer Protection Division, P O Box 517, Frankfort, KY 40602.
*Did this complaint involve an accident?
Other Party Information
* First Name
Middle Name
Last Name
* Insured Company Name
Policy Number
Other Insurance Information
* First Name
Middle Name
Last Name
Address Line1
Address Line2
Country
Zip Code
City
State
*Insured Company Name
Policy Number
Upload Additional Documentation
Please only use pdf, jpg, gif, png, doc, txt.
Upload
Complainant Information
* First Name
Middle Name
Last Name
Address Line1
Address Line2
Country
Zip Code
City
State
*Phone
Extension
*Email
Insured Information (Complainant Information / Individual Harmed)
* First Name
Middle Name
Last Name
Business Name
Address Line1
Address Line2
Country
Zip Code
City
State
*Phone
Extension
*Email
* My complaint is against (select all that apply)
If Other (please specify)
Information On My Policy / Complaint Filed Against (Include Copy of ID Card or Policy)
Insurance Company
Policy Number
Group Number
ID Number
If your complaint falls under another jurisdiction, may we forward it to the appropriate office?
Agent's/Adjuster's Information
* First Name
Middle Name
Last Name
Address Line1
Address Line2
Country
Zip Code
City
State
In the area below, briefly describe your complaint and enter any additional information. (Maximum of 3500 characters)
3500 characters remaining for your description...
When you've entered the required information, press the Submit Complaint button below so your complaint can be processed. Please DO NOT hit the Submit Complaint button more than once.

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