DIFS Business-to-Business Complaint Form

Before You Begin:

For our purposes a Business to Business complaint involves the following: The person making the complaint (Complainant) is a company or individual licensed and regulated by the Department of Insurance and Financial Services (DIFS), and is complaining about another licensee (Respondent) licensed and regulated by DIFS.

If you are a consumer filing a complaint, please use the appropriate complaint form, available from www.michigan.gov/difs or by calling DIFS toll-free at 877-999-6442.

View the Business to Business Complaint Brochure for additional details on the complaint process.

If an investigation or examiniation is opened, the Complainant and the Respondent must understand that investigations and examinations are confidential. However, you may be contacted if further information is needed.

Michigan law, including PA 218 of 1956 as amended, authorizes the review of complaints involving companies or individuals licensed by DIFS. Completion of this form is voluntary and helps us review your allegations.

Just So You Know:

  • We will not intervene in contractual disputes; contract disputes are best handled in civil court.
  • If the contract dispute involves an alleged violation of Michigan law, we will investigate the alleged violation.
  • The Complainant must provide a brief summary of the allegations, must indicate the section of the law he/she believes is being violated, and include supporting documentation.
Warning!

For security purposes, should you be inactive for 20 minutes, this form will reset. To avoid losing your work, a popup will be presented to you after 15 minutes of inactivity. Click the 'Continue' button to keep your work and continue.

 1. About You

Please provide your contact information in case we need to follow up with you on your complaint.

* - Required Field
Your Name
Your Employer

Note: Providing this information is optional and is only used to aid us in reviewing your complaint.

Your Address
Contact Information

*You must provide at least one phone number at which you can be reached in addition to an email address.

If you have a preferred contact number, select the 'preferred number' option next to that number. If only one phone number is provided, this is assumed to be your preferred phone number.

Home is Preferred Contact Number
Cell is Preferred Contact Number
Work is Preferred Contact Number
Anonymity

REPORTING ANONYMOUSLY:
While contact information is required to submit a complaint, should you choose to report anonymously this information will not be disclosed without notification to you regarding the circumstances that require disclosure. Please provide as much accurate contact information as you wish to facilitate additional communication in the review of your concerns.

Would you like to remain anonymous?
Would you like to remain anonymous?
 2. Who Is Your Complaint Against?

In this section, you will be asked to identify who your complaint is against.

You will be able to add as many persons/companies involved with this specific complaint as needed.

* - Required Field
Complaint Regarding
 3. Alleged Code Violations
Please provide the following details for each date in which you feel a section or sections of the Michigan Compiled Laws was violated.
  1. Respondent Responsible
  2. Michigan Compiled Law (MCL)
  3. Section (when necessary)
  4. SubSection (when necessary
  5. Date the incident occurred
To provide multiple dates where the same law is believed to have been violated, enter the MCL, Section and Subsection for each date.

Example MCL's:
  • 500.1201a(1) - MCL: 500, Section:1201a, SubSection: (1)
  • 500.1207(1) - MCL: 500, Section:1207, SubSection: (1)
  • 500.1239 - MCL: 500, Section:1239, SubSection: empty
  • 500.4503 - MCL: 500, Section:4503, SubSection: empty

Alleged Code Violations

 Add Another Violation
* - Required Field
Enter Codes Allegedly Violated:

Example: 445.1672, 500, 490

Example: 22, 249, 10

Example: (g), (a)(b)(c), (1), (3)

 4. Complaint Details

This section gathers additional information about your complaint. Note that much of this information is not required, but the more details you provide, the better we are able to facilitate a resolution.

* - Required Field

Additional Information

Legal Action
Have you filed a lawsuit in this matter?
Have you filed a lawsuit in this matter?
Have you hired an attorney to represent you in this matter?
Have you hired an attorney to represent you in this matter?
Have you filed a police report on this matter?
Have you filed a police report on this matter?
Police Report Locations

Enter the location(s) of the precinct where you filed a police report(s). Click the 'Add Location' button to add as many as you need.

 Add Location

To remove a location from this list, click on the Remove button next to the name.

Amount Involved

Provide whole dollar amounts only

*Details of Your Complaint:

Please list events in the order they happened.

*Describe Your Desired Outcome:

Describe the results you would like to see from this complaint.

Attachments/Documentation:

Documentation relating to your complaint is important. This information helps us to understand details of your complaint. Please attach copies of letters or other documents that will help us review your complaint.

  • Please limit file names to 70 characters or less
  • MS Office, image or PDF files preferred
  • Total file upload is limited to 25 MB

Examples: insurance policy, insurance ID card, bills, bank statements, loan documents, etc.

Attaching a file to your complaint is a two-step process. Step one: Click on the "Choose File" or "Browse" button below to browse your device for a file. Step two: Enter a description of the file and click on the "Upload" button to complete the upload.

Please note: If your attachment is over the 25 MB size limit, please send the attachment(s) to DIFS as a facsimile at 517-284-8837 or through the U.S. Postal Service. Please include your confirmation number when faxing or sending documents to DIFS. Your confirmation number is included in the complaint summary.

1. Select a File:


Examples: Driver's License, Case History, etc.


 Upload

5. Review & Submit

 5. Review & Submit

Review Complaint

Below you will find the details of the complaint you have completed. If you need to make changes, you may use the 'Previous' button or edit links next to each section to make changes.

About You  Edit This Section

Name: 
Company: 

Address:

Contact Information:

Would you like to remain anonymous?  

Who is Complaint Against?  Edit This Section

Alleged Code Violations  Edit This Section

Complaint Details  Edit This Section

Have you filed a lawsuit in this matter?

Have you hired an attorney to represent you in this matter?

Have you filed a police report in this matter?
Police Report Locations:
Amount involved in this complaint?

Details of your complaint:

Desired Outcome:

Attachments:

*Authorization
 Submit Complaint