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Consumer Complaint Form

Please fill in as much information as you can. indicates a required field.

General Complaint Information

Submitter's Information








Insured's Information








Insurance Information




Complaint Description

Please enter a description of the complaint below. Please provide as much information as possible including dates, names, provider information, dates of service and locations. You will have the opportunity to attach supporting files to your complaint once it is successfully submitted.

Fair Resolution

What do you consider to be a fair resolution to your problem?
You will have the opportunity to attach supporting files to your complaint once it is successfully submitted.

Submission

Please read the following statement:

To the best of my knowledge, the information contained herein is true and accurate. I understand that a copy of this form and any or all of the information attached may be sent to the party complained against.

LDI Employees
1702 N. Third Street; P.O. Box 94214; Baton Rouge, LA 70802

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