Investigation request form

Use this form to request an investigation of an insurance agent, adjuster, or broker.

* Indicates required field

Step 1. Your contact information
*Name
(First and last name)
*Address
*City
*State  *Zip Code
*Email
(A copy of this complaint will be sent to this email address.)
*Home Phone
(xxx-xxx-xxxx)
Work
(xxx-xxx-xxxx)
Cell
(xxx-xxx-xxxx)
Step 2. Insured contact information (if different than above)
Name
(First and last name)
Address
City
State    Zip Code
Email
Home phone
(xxx-xxx-xxxx)
Work
(xxx-xxx-xxxx)
Cell
(xxx-xxx-xxxx)
Step 3. Insurance information
*Insurance Company
(Exact and full name of any insurance company involved.)
Policy number
Step 4. Agent or Broker information
Agent/Broker name*
(First and last name of agent or broker Involved.)
Company name
Address
City
State  Zip Code:
Phone
(xxx-xxx-xxxx)
Step 5. Define your problem

*Give a brief explanation of the problem.

If you send supporting documents via fax, U.S Mail, etc, please indicate that you filed a complaint online at the top of the first document. 

(Do not send original documents, copies only please.)

Email documents to: InvestigationRequest@oic.wa.gov or
Mail to:PO Box 40257, Olympia WA 98504-0257 or Fax to:(360) 586-2020

Step 6. Declaration
By filling in my name and date below, I declare the information contained on this form is true and accurate.

*Name
(First and last name)
 *Date
(mm/dd/yyyy)
Step 7. How did you hear about us?
Please tell us how you heard of this office and the services provided.

Relative/Friend
Agent/Broker
Media/Publication
Internet
Other


Questions?

Contact Us:
Phone: (360) 725-7263
Email: InvestigationRequest@oic.wa.gov