Insurance companies can utilize this letter template to seek reimbursement from the person or entity legally responsible for a loss. Please explain your complaint: Try to be brief, but be sure to tell WHAT happened, WHEN it happened and WHERE it happened.You have been sued in court. An insurance company that has made payments to an insured victim is included in the definition of "victim" for purposes of the restitution statute. There are two options for submitting health care complaint forms – either an online electronic complaint form or a printable PDF form. The trial court granted PMA's motion and held that statutorily, PMA's subrogation lien had priority over claimant's attorney's claim for legal fees. The Plaintiff, above named, complaining of Defendants, above named, alleges and says as follows: 1. Sample Forms These sample forms may be useful when filing documents for the civil and family courts. If you have any questions, consult an attorney. File a complaint with your insurance company, agent, broker, or public adjuster.