Complaint Form: Page 1 of 4 Rev: 12/18/13
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INSURANCE FRAUD INDIVIDUAL
COMPLAINT FORM
The information you report on this form may be used to help us investigate violations of state laws. When completed,
mail or fax your form and supporting documents to the office location listed above. Upon receipt, your complaint will be
reviewed by a member of our staff. The length of this process can vary depending on the circumstances and
information you provide with your complaint. The Attorney General’s Office may contact you if additional information is
needed. If you have a claim against the State of Nevada, complete the Tort Claim Form found on our website.
INSTRUCTIONS: Please TYPE/PRINT your complaint in dark ink. You must write LEGIBLY. All fields MUST be
completed.
SECTION 1.
COMPLAINANT INFORMATION
Your Name: ________________________________________________________________________________________
Last First MI
Your Address: ______________________________________________________________________________________
Address City State Zip
Your Phone Number: ________________________________________________________________________________
Home Cell Work Fax
Email: ___________________________________________ Call me between 8am-5pm at: Home Cell Work
Age: Under 18 18-29 30-39 40-49 50-59 60 or older
COMPLAINT IS AGAINST
Business/Provider Name:_____________________________________________________________________________
Individual/Contact: ___________________________________________________________________________________
Last First Job Title (Example: CEO)
Individual/Business Address: __________________________________________________________________________
Address City State Zip
Individual/Business Phone: ____________________________________________________________________________
Work Mobile Fax
Individual/Business Email: ____________________________________________________________________________
Individual/Business Web Site: __________________________________________________________________________
For official use only:
Received by: ____________
Date Received: ___________
Complaint
Type:___________________
Referred to: BCP GI
IFU OML MFU
MFCU PIU WCFU
[Stamp here]
STATE OF NEVADA
OFFICE OF THE ATTORNEY GENERAL
555 E. Washington Ave., #3900
Las Vegas, NV 89101
Phone: 702-486-3420
Fax: 702-486-3768
www.ag.nv.gov
Complaint Form: Page 2 of 4 Rev: 12/18/13
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Name and address of other involved persons or persons who can provide additional information:
SECTION 2.
Did you make any payments to this individual or company? Yes–Continue to Next Question No–Skip to Section 3
How much did the company/individual ask you to pay? ______________________________________________________
Date(s) of payments (mm/dd/yyyy): _____________________________________________________________________
How much did you actually pay? $ ______________ Payment Method: Cash Credit Card Debit Card Check
Financed W
ire Transfer Money Order Cashier’s Check Other: ________________________
Wa
s a contract signed? Yes No If yes, date you signed the contract (mm/dd/yyyy): _____________________
Identify your attempts to resolve the issue(s) with the company, corporation, or organization.
Have you c
ontacted another agency for assistance? Yes No
If so, which agency? _________________________________________________________________________________
Have you contacted an attorney? Yes No
If so, what is the attorney’s name, address, and phone number?
__________________________________________________________________________________________________
Last First Phone
__________________________________________________________________________________________________
Address City State Zip
Is court action pending? Yes No Have you lost a lawsuit in this matter? Yes No
SECTION 3.
Please detail the nature of your complaint against the insurance company, individual or provider listed in Section
1. Include the who, what, where, when, and why of your complaint. (Please include any nicknames or aliases,
identifying information such as Social Security number(s), license plate(s), year/make of vehicle(s), etc.). You may use
additional sheets if necessary.
My complaint is:
Complaint Form: Page 3 of 4 Rev: 12/18/13
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SECTION 4
.
List and attach photocopies of any relevant documents, agreements, correspondence, or receipts that support
your complaint (examples include
billing statements, correspondence, receipts, payment information, witnesses, and any
other document which explains or supports the matters raised in the complaint). No originals. Copy both sides of any
canceled checks that pertain to this complaint.
SECTION 5.
Sign and
date this form. The Attorney General’s Office cannot process any unsigned, incomplete, or illegible
complaints.
I understand that the Attorney General is not my private attorney
, but rather represents the public by enforcing laws
prohibiting fraudulent, deceptive or unfair business practices. I understand that the Attorney General does not represent
private citizens seeking refunds or other legal remedies. I am filing this complaint to notify the Attorney General’s Office of
the activities of a particular business or individual. I understand that the information contained in this complaint may be used
to establish violations of Nevada law in both private and public enforcement actions. In order to resolve your complaint, we
may send a copy of this form to the person or firm about whom you are complaining. I authorize the Attorney General’s
Office to send my complaint and supporting documents to the individual or business identified in this complaint. I also
understand that the Attorney General may need to refer my complaint to a more appropriate agency.
I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge.
___________________________________________ ______________________________________________
Signature Print Name
______________________
Date (mm/dd/yyyy)
SECTION 6. (Optional)
The following section is optional and is intended to help our office better serve Nevada consumers. Please
check the categories that apply to you.
Gender: Male Female
Have you previously filed a complaint with our office?: Yes No
If yes, enter in the approximate filing date (mm/dd/yyyy) of your original complaint: ______________
I am (mark all that apply): Ethnic Identification: Primary Language:
Income below federal poverty guideline White/Caucasian English
Disaster victim Black/African American Spanish
Person with disability Hispanic/Latino Other:
_____________________
Medicaid recipient Native American/Alaskan Native
Military service member Asian/Pacific Islander
Veteran Other: ______________
Immediate family of service member/veteran
Complaint Form: Page 4 of 4 Rev: 12/18/13
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May we provide your name and telephone number to the media in the event of an inquiry about this matter?
Yes No
How did you hear about our complaint form (please choose only one):
Called/visited Las Vegas AG Office Called/visited Carson City AG Office Called/visited Reno AG Office
Attended AG Presentation/Event Another Nevada State Agency/Elected Official Search Engine AG Website
AG Social Media Sites Media: Newspaper/Radio/TV Other_________________________________________
Return original form to:
Office of the Attorney General – ATTN: Insurance Fraud Unit
555 E. Washington Avenue, # 3900
Las Vegas, NV 89101
Fax: 702-486-3768
(Faxed copies will be accepted followed by original)
