Civil Remedy Notice of Insurer Violations
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Complainant
Last/Business Name *  
  First Name  
Street Address *
City, State Zip * ,
Email Address *
Complainant Type: *
Insured
Last/Business Name*     First Name  
Policy # * Claim #*
Attorney
Attorney is Applicable
Last Name* First Name * Initial
Street Address*
City, State Zip* ,
Email Address *
Violation
Insurer Type *  
 
Insurer Name*  
 
Name of individual responsible for violation (if any):*
Type of Insurance *    If other, specify:
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.

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

Comments
Acknowledgement
* The submitter hereby states that this notice is given in order to perfect the rights of the person(s) damaged to pursue civil remedies authorized by Section 624.155, Florida Statutes.

Before submitting a Notice using this system, please verify that all text has been entered correctly and completely. Once the Notice has been submitted, the text cannot be changed or deleted.




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