Get Az Doi Request For Assistance 2010-2025

The Arizona Department of Insurance provides a Request For Assistance form to help individuals address issues related to insurance coverage. This guide will walk you through the process of completing this form online, ensuring you provide all necessary information.

Follow the steps to fill out the AZ DoI Request For Assistance form online.

1. Press the ‘Get Form’ button to obtain the Request For Assistance form and open it in the editor.
2. In Section A, provide your personal information including your date, phone number, fax number, last name, first name, middle name or initial, street address, city, state, ZIP code, and email address. Indicate whether you consent to be contacted via email.
3. If the insured is not yourself, complete Section B with the insured's name, street address, city, state, and ZIP code.
4. In Section C, fill out details about the insurance coverage. This includes the insurance company's name, type of insurance, policy number, policy effective date, and the state where the policy was purchased.
5. For Section D, indicate the type of issue for which you are requesting assistance, selecting from options such as claim denial, delays, premium rates, refusal to insure, policy cancellation, agent handling, or other relevant issues.
6. Complete Section E by attaching your written Statement of Facts, describing your complaint, and enclosing copies of all pertinent documents related to the issue. Ensure you do not submit original documents.
7. Finally, in Section F, review your information and provide your signature to certify that the details provided are accurate to the best of your knowledge. The information related to your complaint will be publicly recorded.
8. After filling out the form, you can save your changes, download the document for your records, print a copy, or share it as needed.

Complete your Request For Assistance form online to address your insurance concerns effectively.