DIFS Consumer Complaint Form

Before You Begin:

We encourage consumers to first attempt to resolve disputes directly with their insurance and/or financial service entity. If a resolution cannot be reached, our department can help try to resolve your dispute.

If you choose to file your complaint online you will need to have a valid email address and the ability to include relevant documentation as attachments. If you do not have a valid email address or the means to provide documents electronically we recommend filing your complaint by fax or mail.

For more information regarding mail-in submissions please visit DIFS How to File a Complaint to download the appropriate form.

Types of Complaints We Assist With:

DIFS is able to assist in resolving complaints across several industries including insurance, banking, credit union, mortgage and other consumer financial products.

*At this time our system does not allow for the online submission of the following types of complaints: Business-to-Business, Provider Clean Claims, and Proof of Claim Against a Mortgage Company Bond.

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 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.

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?
 2. Other Involved Parties

This area allows you to identify additional individuals or companies we can discuss your complaint with such as your family member, attorney, provider, etc.

* - Required Field
required*Do you have any persons or companies you wish to include as a contact regarding this complaint?
*Do you have any persons or companies you wish to include as a contact regarding this complaint?
 3. 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
 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

Consumer Lending/Banking Complaint Information

Additional details are optional.

Name of the Borrower
Name of the Account Holder

Financial Institution Contacts

Enter the name(s) of the people you are dealing with at the financial institution. Click the 'Add Name' button to add as many people as you need to.

Property Information
required*Is the property in foreclosure?
required*Is the property occupied?
required*Is the property in a mobile home park?
Property Address
Insurance Complaint Information

Additional insurance information is optional unless otherwise marked.

Name of the Insured

If there is more than one date of service/loss, please use the initial date of service/loss. Additional dates may be entered in the details of your complaint section below.

If you are unsure if policy is part of an employer or group plan, please select individual policy.

Individual Policy Details:
Group Policy Details:
*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 filenames 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 25mb 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.

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


 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.

Name: 

Address:

Contact Information:

Have you filed a lawsuit in this matter?

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

Other Involved Parties  Edit This Section

Who is Complaint Against?  Edit This Section

Complaint Details  Edit This Section

Consumer Lending/Banking Information

Name of Borrower:

Name of Account Holder:

Financial Institution Contacts:

Property Information

Is the property in foreclosure?

Foreclosure Date:

Is the property occupied?

Is the property in a mobile home park?

Property Address:

Insurance Information

Name of Insurance Company:

Name of Insurance Agent:

Name of Insured:

Date of Service/Loss:

Insurance Plan Type:

Insurance Policy Number:

Employer:

Employer Contract Number:

Details of your complaint:

Desired Outcome:

Attachments:

*Authorization