Complaint Form   SCDOI Connect Login
Complaint Print a blank PDF version of this form
1. Complainant Information
Name *
Email *
Street Address *
City *
County *
State *
Zip Code *
Daytime Phone Number *
I'm filing this complaint as the *
Have you or anyone previously written or faxed to the South Carolina Department of Insurance regarding this complaint? *
If yes, when?
 
2. Policyholder and Policy Information
Policyholder Name
Policyholder Email
Policy #
Claim #
ID #
Date of Loss
Name of Insurance Company Involved *
Phone *
Name of Agent/Adjuster *
Phone *
Name of Employer Offering Coverage
Type of Insurance (Check at least one and all that apply) *


Please Specify:
 
3. Reason for Complaint (Check at least one or all that apply) *
 



Please Specify:
Discrimation Based On:

 
4. Attorney Information
Does an attorney represent you in this matter?
If you answered 'Yes',we will need written authorization in order for us to intervene in this matter.You may provide this authorization by: (1)including a letter of authorization with your complaint that is signed by your attorney on their letterhead; or (2) having your attorney co-sign the complaint form and including their phone number.Alternatively you may elect to have your attorney file the complaint on your behalf.
 
5. Below, please describe in detail your complaint and what you consider to be a fair resolution to the complaint.
 
Description
6.Upload Co-Operative Files



Consent to Release Information: The information I have given above is true and accurate to the best of my knowledge. This information may be forwarded to the insurance company, if necessary for the investigation of this matter. I understand that under South Carolina’s Freedom of Information Act this complaint becomes a public record once my file is closed. (Medical and personal records will remain confidential).

Disputes involving Self-Funded Employer Benefit Plans come under the jurisdiction of the United States Department of Labor. 1-866-275-7922
South Carolina State Employees or Retirees medical, dental, disability and long term care issues come under the jurisdiction of the SC State Insurance Plan. 1-888-260-9430 or 803-734-0678