Hawaii Insurance Division Complaint/Inquiry Form

When a complaint is filed with the Insurance Division, the Compliance and Enforcement Branch conducts an investigation to assure compliance with the applicable statutes and rules. Appropriate disciplinary actions are taken by the Compliance and Enforcement Branch when necessary. To file a complaint, a complaint form must be filled out and submitted to the Hawaii Insurance Division.

Assistance is needed concerning:*
- A complaint
- An inquiry
Your Contact Information
Name*
Prefix First Middle Last Suffix
First and Last name are required.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Best Contact Phone Number*
Email
1st Preferred Form of Contact*
- Phone Number
- Email
- Mail
If email, please be sure to include an address above.
2nd Preferred Form of Contact
- Phone
- Email
- Mail
If email, please be sure to include an address above.
Insurance Company/Agency/Individual Information
Name of Insurance Company/Agency/Individual*
Please indicate policy number and/or claim number, if known:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Complaint/Inquiry
State the relief sought:*
State a Summary of the Complaint/Inquiry:*
Supporting Documents and Photos
Drop files here or

Accepted file types: jpg, jpeg, png, pdf, jpg, jpeg, png, pdf, Max. file size: 5 MB.
Maximum number of 10 files. Maximum file size is 5MB. Only JPG, PNG, and PDF file types allowed.
Acknowledgement*
- By checking this box, I acknowledge that a copy of this form may be sent to the insurance company and/or individual involved.
Date Submitted
MM slash DD slash YYYY
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Hawaii Insurance Division Complaint/Inquiry Form

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