SURETY BAIL BOND AGENT 
COMPLAINT FORM
YOUR INFORMATION:
Name:	     	
Street:	     	
City:	     	State:	     	Zip Code:	     	
Phone:	     	
COMPLAINT IS BEING FILED AGAINST:
Name of Surety Bail Bond Agent :	     	
License Number, if available:	     	
Address, if available:	     	
Employer, if available:	     	

EXPLAIN YOUR COMPLAINT FULLY IN THE ORDER OF EVENTS IN THE SPACE PROVIDED BELOW.

pLEASE SIGN, dATE AND RETURN THIS FORM TO THIS DEPARTMENT WITH COPIES OF ANY AVAILABLE MATERIAL/DOCUMENTS PERTINENT TO AND IN SUPPORT OF YOUR COMPLAINT (STATEMENTS OF witnesses, POLICE REPORT DESCRIBING incident, PAYMENT RECEIPTS, CORRESPONDENCE you have written or received, or other documentation concerning your complaint).  If your complaint concerns an insurance advertisement, attach a copy of the advertisement.  PLEASE TYPE, PRINT, OR WRITE CLEARLY.  USE ADDITIONAL SHEETS, IF NECESSARY.
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	

PLEASE DO NOT SEND ORIGINALS

I HAVE ENCLOSED COPIES OF CORRESPONDENCE AND DOCUMENTS RELATING TO THIS MATTER WHICH WILL ASSIST YOUR INVESTIGATION OF THE COMPLAINT.  I UNDERSTAND THAT COPIES OF THIS FORM AND ANY OF THE ENCLOSED DOCUMENTS WILL BE SENT TO ANY PERSON AND/OR FIRM DEEMED NECESSARY BY YOU TO COMPLETE YOUR INVESTIGATION.

Signature of Complainant:		Date:	     	

MAIL COMPLAINT TO: CT INS DEPT – LICENSING,  PO BOX 816, HARTFORD, CT  06142-0816 or
FAX COMPLAINT TO:    860.297.3978 (ATTENTION:  LICENSING)

BB Complaint Form 9/22/04