[DC GOVERNMENT] Flood Insurance Consumer Complaint Form

Flood Insurance Consumer Complaint Form - DISB

Title

Day Phone

Evening Phone

Cell Phone

Best Time To Call

Ward (If District Resident)

Fax No.

For demographic purposes only: Please select your age range below.

under 25

25-49

50-64

65+

Company

Phone Number

Fax Number

Type of product in question: Please check the appropriate box(es) below

Insurance

Other

If other, please specify

Type of problem: Please check the appropriate box(es) below

Claim Denial/Dispute/Delay

Unsuitable Transaction

Misrepresentation by Company or Employee

Unlicensed Activity

Refund Due

Payment not Credited

Other

If other, please specify

Account or Policy #

How much money is in dispute?

As fully as possible, describe the events in the order in which they happened, including specific dates, names of involved individuals, and the financial institution’s actions to which you objected. Upload supporting documentation at the end of the form.

If you have attempted to resolve your complaint directly with the financial institution, please provide the information below. If not, proceed to next question.

Name of person(s) contacted

Title of person(s) contacted

Telephone or e−mail of person(s) contacted

Financial institution's response

Have you contacted any other financial services regulator, such as other state regulators, The U.S. Securities and Exchange Commission, The Financial Industry Regulatory Authority, The Office of the Comptroller of the Currency, etc.

Yes

If yes, please describe your contacts.

How would you like this complaint resolved?

If you believe that financial fraud or criminal activity has transpired, please check this box and state why you believe this to be a fraudulent action.

State why:

Below is a field to submit supporting documents for your complaint through our secure site. The field can accommodate a file up to 5MB and supports documents in Word and PDF. If you need to submit a file in a different format, contact our Consumer Services Division at floodcomplaints@dc.gov. You will have the opportunity to submit additional documentation after your complaint has been assigned to an investigator.

Additional Documents

Click Here to Upload

The information requested on this form will be used to investigate and respond to your complaint. In our effort to resolve your issue, this information may be disclosed outside the agency to the financial institution that is the subject of your complaint; to any involved third parties; to the federal, state, or local agency that has supervisory authority over the subject financial institution; to appropriate federal, state, or local law enforcement authorities if a violation or possible violation of law is discovered; or to a legislative office in response to any inquiry made at your request.

I wish to file a complaint against the financial institution named in this complaint form, with the understanding that DISB may conduct an investigation on my behalf. However, I understand that DISB does not have the authority to act as my representative in the subject matter of this complaint. I understand that completion of this form is voluntary, but failure to provide requested information and/or failure to sign this form may delay or preclude investigation of my complaint. I understand that, as part of DISB’s investigation on my behalf, a copy of this form may be forwarded to the financial institution that is the subject of your complaint or other third−parties as referenced in the Privacy Statement above.

I have read and agreed to the terms above.

I Agree and Accept

Name

Date

Recaptcha Response

Be sure to verify that you are not a robot by using the Captcha tool at the below.

Having reCaptcha issues? Click here to reset the widget.