Complaint Form

Customer Information

*Your Name:

*Address1:

Address2:

*City:

*State:

*Zip Code:

*Phone:

 Ext.:

*Email:

Filing Type:

*Type of Insurance:

Policy/Claim Information

*Policy Number:

Claim Number:

Date of Loss:

Group Plan Number:

Name of Group Plan Holder:

Name of the Business:

Business Address:

Business Phone Number:

 

Agent Information

Agent Name:

*How do you want us to respond to you? (Select one from the options below.)

U.S. Mail

Fax

Telephone

Email

Please provide the following information which pertains to your choice above.

 

*Comments

 

Have you contacted anyone at The Hartford about this feedback?

Yes No

If yes, please provide the name and phone number of your contact below.

Contact Name:

Contact Phone Number:

 

Please complete the following section if you are represented by an attorney.

Attorney Name:

Address1:

Address2:

City:

State:

Zip Code:

Phone Number:

  Ext.: