The New York Department of Insurance form serves as a critical link between consumers and the insurance regulatory framework of the state, ensuring that grievances and inquiries related to insurance matters are addressed effectively and efficiently. Housed under the auspices of the Consumer Services Bureau, located at both 25 Beaver Street in New York, NY, and the Empire State Plaza Building #1 in Albany, NY, the form provides a structured way for individuals to file complaints against insurance entities licensed to operate within New York State. Despite its comprehensive approach to collecting relevant information—from the name and address of the complainant to detailed descriptions of the complaint, including policy or claim numbers and dates of loss—it's essential to note the limitations set forth by the department. Specifically, the Department does not offer legal advice, act as a legal representative, or provide recommendations or ratings on insurers. To facilitate a thorough investigation, complainants are encouraged to submit copies (not originals) of any supportive documents or photographs alongside their complaint forms. Acknowledgment of the complaint, including a file number for future correspondence, is provided to ensure that the process is transparent and that further inquiries can be managed effectively. This initiation requires an understanding from the complainant that information submitted can be shared with the respondent for a comprehensive review, underpinning the collaborative and investigative nature of the department's approach to resolving insurance-related issues.
| Question | Answer |
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| Form Name | New York Dept Insurance Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | InsuranceCompla intForm state of new york dept of insurance form |
New York State Insurance Department
Consumer Services Bureau
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25 Beaver Street |
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Empire State Plaza Building #1 |
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New York, NY 10004 |
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Albany, NY 12257 |
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(212) |
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(800) |
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Fax (212) |
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Fax (518) |
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Complaint Is Against |
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On Behalf Of |
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Policy/Claim Number/Date Of Loss |
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The Insurance Department investigates insurance complaints involving licensed insurance entities.
The Insurance Department CANNOT: Act as your lawyer, give legal advice, recommend, or rate insurers.
Use the other side of this form to provide us with the details of your complaint or inquiry. Include copies of papers or photos you believe will assist us. Do not send originals!
You will receive a written acknowledgment with your file number(s) by mail. If you wish to send further correspondence, please include that number. If you fail to do so, it may slow down the processing of your complaint.
I authorize the respondent to furnish to the Insurance Department any information related to this matter. I am enclosing copies of any correspondence or other papers which I feel would help your investigations. I understand that a copy of this form and any or all of the enclosed information may be sent to the respondent.
Signature ________________________________ Date: ______________________________