• 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.


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  • 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            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

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  • AUTO BODY SHOP COMPLAINT FORM

    Complainant Information
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  • AUTO BODY SHOP COMPLAINT FORM

    Licensee Information – Who is the complaint against?
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  • AUTO BODY SHOP COMPLAINT FORM

    Insured/customer insurance information (if known and applicable)
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  • AUTO BODY SHOP COMPLAINT FORM

    Reason for complaint / NHID Jurisdiction
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  • AUTO BODY SHOP COMPLAINT FORM

    Required narrative and desired outcome
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  • **************    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.

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  • AUTO BODY SHOP COMPLAINT FORM

    Release of Information
  • Insured / Customer Information

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  • Insurance Information

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  • 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.

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