Section 250.EXHIBIT A Grievance Form

Grievance

Discrimination Based on Disability

It is the policy of the Illinois Department of Insurance to provide assistance in filling out this form. If assistance is needed, please ask:

ADA Coordinator – Department of Insurance

320 West Washington Street

Springfield IL 62767-0001

( 217 )782-4515 (Voice); (866)323-5321 (TDD)

Name:

Address:

City, State and Zip Code:

Telephone No.:

The Best Means and Time for Contacting:

Program, Service, or Activity to which Access was Denied or in which Alleged Discrimination
Occurred:

Date of Alleged Discrimination:

Nature of Alleged Discrimination:

(Attach additional sheets, if necessary. If the grievance is based on a denial of requested reasonable modification, please fill out the back of this form.)

I certify that I am qualified or otherwise eligible to participate in the program, service or activity and the above statements are true to the best of my knowledge and belief.

Signature

Date

Complainant/Authorized Agent

Please give to the ADA Coordinator at the address listed above.

For Office Use Only

Date Received:

By:

(BACK OF FORM)

Please fill out this part of the form if this grievance is based upon the denial of a requested reasonable modification. A reasonable modification will be made to make programs, services and activities accessible. Reasonable accommodations could include such things as providing auxiliary aides and devices and changing some policies and requirements to allow an individual with a disability to participate. This portion of the form should be filled in to the extent you know the answers. The form may be submitted even if this portion is incomplete.

Reasonable modification requested:

The date the reasonable modification was requested:

The person to whom the request was made:

The reason for denial:

Estimated cost of modification (if an assistive device, such as a TDD or optical reader, or commodity or service to which a cost is readily known):

Why is the requested modification necessary to use or participate in the program, service or activity?

Alternative accommodations that may provide accessibility:

Any other information you believe will aid in a fair resolution of this grievance:

(Source: Amended at 39 Ill. Reg. 5618, effective March 30, 2015)