NAME OF COMPANY: _______________________________

A B C D E F G H Function Code Reason Code Line Type Company Disposition After Complaint Receipt Date Received Date Closed Insurance Department Complaint State of Origin Company Identification Number Agents Number Staff Adjusters Number Independent Adjuster

A

B

C

D

E

F

G

H

Function Code

Reason Code

Line Type

Company Disposition After Complaint Receipt

Date Received

Date Closed

Insurance Department Complaint

State of Origin

Company Identification Number

Agents Number Staff

Adjusters Number

Independent Adjuster

[7/1/97; Recompiled 11/30/01]