Complaint form to U.S. Justice Department

COMPLAINT FORM, CONCERNING 1963 CONSENT DECREE
DATE: ________________

THE FOLLOWING COMPLAINT IS FILE AGAINST ________________ INSURANCE COMPANY. FOR ACTIVITIES VIOLATING THE CONSENT DECREE UNDER CIVIL ACTION NO.63 CIV.3106. THE CONSENT DECREE STIPULATES THAT INSURERS MAY NOT INTERFERE OR CONTROL THE COST OF LABOR, PARTS, OR DISCOUNTS OUTSIDE THE BUSINESS OF INSURANCE.

NAME OF INS. COMPANY __________________________________________
ADDRESS OF INS. COMPANY _______________________________________
NAME OF APPRAISER ______________________________________________
ADDRESS IF INDEPENDENT_________________________________________
ENCLOSED COPY OF INSURANCE APPRAISAL________________________
ENCLOSED COPY OF SHOP ESTIMATE _______________________________
ENCLOSED COPY OF DESIGNATED REP FORM _______________________
TYPE OF CLAIM INSURED OR CLAIMANT_____________________________

DETAILS OF COMPLAINT: __________________________________________
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ATTACH ADDITIONAL PAGES IF NECESSARY.

SIGNED: _______________________________________DATE: _____________

DAYTIME PHONE: ________________________________

Mail complaint to : Anti-Trust Division (Communication & Finance Section)
Suite 9500, 600 East St. NW Washington, DC 20530