4 Ill. Adm. Code 250.EXHIBIT A
A Grievance Form
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: