Civil Remedy

Civil Remedy Notice of Insurer Violations

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Filing

DFS File #:


Filing Dates: Enter date range, begin date only, or end date only. To search for a single date, enter the desired date in both fields.
Submission Date:		-

Complainant

Last/Business Name

First Name

Street Address

City, State Zip

Email Address

Complainant Type:

Insured

Last/Business Name				First Name
Policy #				Claim #

Attorney

Last Name

First Name

Initial

Street Address

City, State Zip

Email Address

Violation



Insurer Name
Name of individual responsible for violation (if any):
Type of Insurance

Reason for Notice		If other, specify: Add

Statutory provision(s) which the insurer allegedly violated.
Add


Specific policy language that is relevant to the violation. Enter all words or phrases (one at a time) that should be used to filter. Add


Facts and circumstances giving rise to the violation. Enter all words or phrases (one at a time) that should be used to filter. Add

DFS-10-363
Rev. 10/14/2008