Formal Complaint Form
Your complaint will be processed most efficiently if you can provide the last four digits of your local NRIA Authorized Contractor or Lenders number which is located on any notice(s) you may have received from us.  If you know the last four digits of your local NRIA Authorized Contractor or Lender, please enter them in the appropriate field provided below.
Tell us about your problem:
(Please limit your responses to the approximate amount of text that will fit into the boxes below, without scrolling)
My Complaint Involves
Last 4 Digits of Contractor/Lender Code
Contractor/Lender Company Name
First Name
Last Name
Street Address
Apt/Suite #
Daytime Phone
Evening Phone
Fax Number
Email Address
Primary Classification
Secondary Classification
Tell us about your problem
Description of Product/Service Purchased
Model Number(s)
Contract/Account/Policy #
Order #
Date of Purchase (mm/dd/yyyy)  
Date Problem Occurred  
Date First Complained (mm/dd/yyyy)  
Date of Second Compaint (mm/dd/yyyy)  
Date of Third Complaint (mm/dd/yyyy)  
Payment(s) Made?
Salesperson Title
Salesperson First Name
Salesperson Middle Name
Salesperson Last Name
Salesperson Suffix
Purchase Price $
Disputed Amount $
Desired Settlement
What is Your Desired Outcome?

Please use the scroll bar on your web browser to review all of the information you have provided.
If all information is correct, click the submit button above to submit your complaint.