AID Electronic Complaint Form

Please fill out as much information in the form below as possible to assist us in following up on your complaint. Once we receive your correspondence, it will be assigned to on of our investigators, who will review it and take the necessary steps to resolve this matter.

Please be aware that if you print this screen in order to fax it in, all text may not appear, instead please use the Downloadable form .

Fields with an asterisk (*) beside them are required.

First name*   
Last name*   
Address*   
City*   
State*   
Zip*   
Phone   
Email   
Fax   
Insurance Company   
Insured   
Policy #   
Effective Date   
Claim #   
Occurance Date   
Agent's Name   
Insurance Type   
Comments