Consumer Insurance Services
500 James Robertson Parkway, 4th Floor
Nashville, TN 37243-0574
(800) 342-4029 - (615)741-2218
FAX (615) 532-7389
Email Us Email CIS

ONLINE CONSUMER COMPLAINT FORM

Please Complete this form and submit it to us. We will inform you of your assigned investigator once your file has been setup. You may wish to provide documentation that supports your complaint. Please do not send originals!

Warning: The information submitted on this internet form is not secure/encrypted during its transmission from your computer to the State of Tennessee's computer system. It is secure once received on the State's computer system. Please be aware of this fact and do not enter sensitive information.

Click here to download printable complaint form if you prefer not to continue with online complaint form.

Complainant Information
* denotes required field
Prefix Mr. Mrs. Ms. Dr. File Number Assign
First Name*   Last Name*   
Business Name  
Street Address
City        State    Zip Code
Phone Numbers               
Email Address County  
Age Group Under 25 25 to 49 50 to 64 Over 65 Not Applicable
Insurance Information
My Complaint Is Against:
my insurance company my agent
other party's insurance company other
Type Of Coverage Auto Homeowners Life Health Other
Insurance Company 
Agent
Agent's Phone Number
Date of Loss or Incident
If Policy was terminated 
Cancellation Date:   Effective Date:
Adjuster's Name     
Insured:
Company Reference Policy Claim Number
Reason(s) for complaint
Claim Denial Claim Delays Low Settlement Offer
Premium & Rating Premium Billing Premium Refund
Information Requested Cancellation Non-renewal
Rate Classification Policy Delivery    
Other (Describe)

Give a Brief Description of the problem:
What actions should be taken to resolve your complaint?
If you are not aggrieved party, what is your relationship with them?  
Declaration
I Declare that the information I have furnished is true and accurate (Please Check this box)* 
Type your full name *  Date*