TEXAS DEPARTMENT OF INSURANCE
COMPLAINT RECORD FORM
1 |
2A |
2B |
3 |
4 |
5 |
6 |
7 |
8 |
Complaint Identification Number (and Agent Identification Number, if appropriate) |
Function Code Category |
Reason Code Category |
Line Type |
Complaint Disposition/ Resolution |
Date Received |
Date Closed |
Complaint Source |
State of Origin |