Request for assistance - Arizona Department of Insurance - AZ 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with SECTION A: Information About You. Fill in your date, phone number, last name, first name, middle name (if applicable), street address, city, state, and ZIP code.
3. If the insured is someone other than yourself, complete SECTION B: Information About the Insured with their details including last name, first name, phone number, email address, and street address.
4. In SECTION C: Information About the Insurance Coverage, provide the insurance company’s name, type of insurance (e.g., life, health), policy effective date, policy number, and state where purchased.
5. SECTION D requires you to consent to share information. List individuals authorized to access your complaint details along with their relationship to you.
6. In SECTION E: Type of Issue/Question, select the issue you are facing such as claim denial or policy cancellation.
7. Finally, complete SECTION F: Statement of Facts by describing what has occurred with your insurance company and what assistance you seek from the Department of Insurance.

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