Instructions For Proof Of Claim Form printable pdf download

GRAMERCY INSURANCE COMPANY (“GRAMERCY”)

INSTRUCTIONS FOR PROOF OF CLAIM FORM

A claim against the assets of the Gramercy receivership estate must be made by filing a Proof

of Claim (“POC”). Failure to follow these instructions could result in the denial of your claim.

1. You may file a POC if you:

a) are a policyholder, and have a claim under your Gramercy policy;

b) have a claim against an insured of Gramercy that is covered by a Gramercy policy; or

c) are owed an amount of money by Gramercy for any other reason.

2. A policy claim may be payable by a guaranty association. Information about the Texas Property and

Casualty Insurance Guaranty Association is available at Information about other

states’ guaranty associations is available at Do not use the

Gramercy POC form to file a claim with a guaranty association.

3. You may file a POC for any amount due under a Gramercy policy that is not covered in whole or in

part by a guaranty association, including unearned premium.

4. All applicable blanks on the POC form must be completed.

5. Each person making the claim must be identified clearly, and a separate POC form submitted for each

person or claim. If a POC is submitted on behalf of another person, evidence of the authority to file

the claim must be attached.

6. If the amount of the claim has not yet been determined, state “undetermined” in the blank for “Total

Amount of Claim.”

7. Provide an explanation of your claim, and include any documents supporting your claim. If you are

involved in a lawsuit against Gramercy or an insured of Gramercy, include the case name, docket

number and the court in which it is pending.

8. The POC must be signed before a notary public. A POC that is not notarized will not be accepted.

9. You should keep a copy of the completed POC, and any proof that it was mailed or received.

10.

POCs must be sent by U.S. Mail, courier service, or hand delivery to the address on the POC form

and received by the SDR no later than 11:59 p.m. CST on February 26, 2015. POCs submitted by e-

mail or fax will not be accepted.

NOTICE TO PERSONS WITH CLAIMS AGAINST INSUREDS OF GRAMERCY

Section 443.256 of the Texas Insurance Code contains requirements for claims against a person who was

insured by Gramercy (an “Insured”). By filing a POC, a claimant waives any right to pursue the personal

assets of an Insured for the claim, to the extent of the coverage or policy limits provided by Gramercy. A

claimant who files a POC must seek satisfaction of the claim solely from any distribution from the

receivership, and any payments from a guaranty association, to the extent of the coverage or policy limits.

The waiver does not release an Insured with respect to a claim in excess of the coverage or policy limits.

The waiver may be voided as described in Section 443.256 of the Texas Insurance Code.

COMPLETED POCS MUST BE RECEIVED BY THE SDR

NO LATER THAN 11:59 P.M. CST, FEBRUARY 26, 2015.

Additional information is available at

Instructions For Proof Of Claim Form