Auto Body Shop Complaint Form

Getting Started

Terms and Conditions
By clicking next, you are agreeing to the terms of this electronic body shop complaint process. All information is secure and no personal information is kept by NHADA. NHADA will submit the form to the New Hampshire Insurance Department on your behalf. Personal information will be deleted upon form submittal.

Please categorize your complaint

Steering Short pay for paint and materials Short pay for mechanical AM parts Scans and calibration OEM procedures (structural) OEM procedures (non-structural)

CONSUMER CONSENT AND RELEASE

Customer Signature Here
NOTE: If you would like to complete the form at a later time please use the save function below. You will be prompted to create an account.
I hereby release my insurance information to insert shop name here and I authorize the New Hampshire Insurance Department (NHID) to provide to this individual any insurance information related to my insurance claim described below and communications received from the insurance company, its agents or representatives. I understand that this information may include personal financial information, medical records, personal health information or other confidential information. I understand that it is possible that the person receiving this information may re-disclose this information to others. I discharge and release the NHID from any responsibility or liability related to the release of these records or any re-disclosure.
NOTE: This is the name and signature of your customer, not the individual filling the form out from the business
Insured/Customer Name

First Name M. Last Name
Insured/Customer Signature

Clear
Date

Month Day Year
Date
If applicable, provide customer address and contact info. NOTE: This is not the motor vehicle business.

Yes, I have customer address and contact info
Insured/Customer Address

Street Address

Street Address Line 2

City State

Zip Code
Insured/Customer Phone Number

Area Code Phone Number
Insured/Customer Email
example@example.com

AUTO BODY SHOP COMPLAINT FORM

Complainant Information
Complainant's Name (Body Shop Employee/Form-Filler)

First Name Middle Initial Last Name
Body Shop's Name
Body Shop's Phone Number

Area Code Phone Number
Email
example@example.com
Body Shop's Mailing Address

Street Address

Street Address Line 2

City State (abbr.)

Zip Code

AUTO BODY SHOP COMPLAINT FORM

Licensee Information – Who is the complaint against?
Select Licensee Type

Insurance Company Adjuster/Appraiser
Licensee's Name
Licensee's Address

Street Address

Street Address Line 2

City State (abbr.)

Zip Code
Licensee's Phone Number

Area Code Phone Number

AUTO BODY SHOP COMPLAINT FORM

Insured/customer insurance information (if known and applicable)
Insured/Customer Name
7Insured/Customer Policy #
Claim #
Date of Loss

Month Day Year
Date

AUTO BODY SHOP COMPLAINT FORM

Reason for complaint / NHID Jurisdiction
Reason for complaint (check all that apply):

Illegal steering law (RSA 417:4, XX) Aftermarket parts law (RSA 407-D) Claim settlement delays (Ins. 1002.05) Settlement offer does not represent fair and reasonable pricing (Ins. 1002.17a) Work performed does not meet the usual and customary guarantees as to materials and workmanship (Ins. 1002.17a) Insurer and chosen repair shop not able to agree on cost of repair (Ins. 1002.17g)

AUTO BODY SHOP COMPLAINT FORM

Required narrative and desired outcome
Please describe your problem in detail.
Attach additional pages, if necessary. Please include copies (not originals) of important papers, letters or other information that is relevant to this matter.

Browse Files

Cancel of
What would you consider to be a fair resolution of your problem?

The carrier should reimburse the repairer for all costs incurred in the proper and safe repair of the vehicle. The carrier should reimburse the policy holder so that I can cover all costs incurred in the proper and safe repair of the vehicle.
13-hidden-field. Fair resolution:
************** COMPLAINT INVESTIGATION DISCLOSURE *************
This form must be complete. All documents relevant to the complaint must be submitted with this form. The Department will not consider material, which could have been submitted with this form after the form has been filed with the Department.
The submittal of this complaint form will initiate an investigation of any Department licensee who is the subject of the identified complaint. Pursuant to RSA 400-A:16, II the Department will request and receive information and documentation, relevant to this investigation, from the named parties. Please note relevant information may include medical records. Also, the Department may share with the Department licensee any medical information and/or records provided in connection with this complaint.

AUTO BODY SHOP COMPLAINT FORM

Release of Information
Insured / Customer Information
Insured/Customer Name

First Name Middle Name Last Name
Mailing Address

Street Address

Street Address Line 2

City State (abbr.)

Zip Code
Phone Number

Area Code Phone Number
Email Address
example@example.com
Insurance Information
Insurance Company Name:
Policy Number:
Insurance Company Phone No.

Area Code Phone Number
Claim Number:
Customer Name

First Name Last Name
ACKNOWLEDGEMENT

Must be signed by the individual (body shop) who will RECEIVE insurance information
I acknowledge that the above Release of Information will permit me to receive insurance information related to a claim filed by the individual signing the Release of Information. I understand that the NHID cannot disclose insurance information, if a Release of Information is not signed. I also understand the information I may receive may contain personal financial information, medical records, personal health information, or other confidential information.
Body Shop Representative (Print Name)
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Getting Started