Consumer Coverage Disclosure Act Complaint Form

Title

Name

Please fill out this field.

Phone

Ex: 555-555-5555

E-Mail

Preferred Contact Method

Dates of Employment (Start)

Dates of Employment (End)

Name of Establishment

Address

Owner/Contact Name

Business Telephone

My Supervisor

1. Check HERE if your employer did not provide you a list of written covered benefits included in the group health insurance.

Yes, I confirm.

a. If checked YES to the above statement, did your employer fail to provide you the list of written covered benefits upon

Hire

Annually

Upon Request

Check all that apply.

b. Date(s) did the violation occur (the date you requested the list of covered benefits and were denied?

Additional Violation Occurrences

2. Please identify how your employer distributes health insurance information

Email

Website

Paper

Other

Check all that apply.

Other Distribution Methods

3. If your employer does not distribute the list at all, please indicate in the line below how you obtain health insurance benefit information

4. If the manner of distribution is an issue, please describe

5. Does your employer offer just one group plan or multiple plans? Please describe:

6. Please add any other relevant information

I confirm and certify the above information and statements made are true and correct to the best of my knowledge.

Confirm

Signature

Attachments

Choose Files

Multiple files can be uploaded by holding down Shift or Ctrl while selecting.

Submit

Reset