Office of the Lieutenant Governor, VI · St. Thomas
Insurance Complaint Form
The Insurance Complaint Form lets a complainant report an insurance-related issue to the Office of the Lieutenant Governor’s Division of Banking, Insurance and Financial Regulation.
What this form is
Use this form to submit an insurance complaint to the Division of Banking, Insurance and Financial Regulation. It asks for the complainant’s contact information and status, details about the person or company complained about, coverage type, and reason for the complaint. The form also provides space to summarize the complaint and sign and date it.
Who needs it
A person reporting an insurance complaint, such as an insured, third party, beneficiary, broker, or agent, can complete this form.
How to submit it
The form lists the Division’s addresses at 5049 Kongens Gade, Charlotte Amalie, St. Thomas, VI 00802, and 1131 King Street, Suite 101, Christiansted, VI 00820. It also lists telephone and fax numbers, but does not state a submission method.
About notarization
This document is signed and dated without a notary; the form requests the complainant’s signature and date, with no notarized or sworn attachment identified.
How to submit this form
- 1
Download The Form
Download the Insurance Complaint Form.
- 2
Complete The Complaint Details
Fill in your contact information and status, the subject of the complaint, coverage type, reason, and complaint summary.
- 3
Sign And Date
Sign and date the form.
- 4
Submit To The Division
Use the Division addresses listed on the form; it does not specify a submission method.
Frequently asked questions
- Do I need a notary for the Insurance Complaint Form?
- No. The form has no notary block; it asks the complainant to sign and date it, and identifies no notarized or sworn attachment.
- How do I submit the Insurance Complaint Form?
- The form lists the Division’s office addresses in Charlotte Amalie and Christiansted, along with telephone and fax numbers, but does not specify how to submit the form.
- What information does the Insurance Complaint Form request?
- It asks for complainant contact details and status, information about the person or company complained about, coverage type, the reason for the complaint, and a written summary.
Need something notarized?
This Insurance Complaint Form doesn’t need a notary — but if you have another Office of the Lieutenant Governor form that does, a commissioned online notary can help.