Instructions For Proof Of Claim Form Page 2
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1
2
3To Be Completed by SDR
Filing Deadline:
POC # ______________________
February 26, 2015
Claim # _____________________
11:59 p.m. CST
Date Received _______________
GRAMERCY INSURANCE COMPANY
PROOF OF CLAIM
Return this completed Proof of Claim form and supporting documentation to the
applicable address below. A Proof of Claim must be received by the SDR no later than
11:59 p.m. CST on February 26, 2015.
BY MAIL:
BY COURIER OR HAND DELIVERY:
Resolution Oversight Corporation
Resolution Oversight Corporation
Special Deputy Receiver
Special Deputy Receiver
Gramercy Insurance Company
Gramercy Insurance Company
P.O. Box 2077
222 East Houston St., Suite 550
San Antonio, Texas 78297-2077
San Antonio, Texas 78205
Please read the Proof of Claim instructions carefully prior to completing this Proof of Claim.
Please print or type.
_________________________________________________________
$_________________________
Name of Claimant
Total Amount of Claim
_________________________________________________________
_________________________
Street Address
Soc. Sec. or Tax ID Number
_________________________________________________________
_________________________
City
State
Zip
Telephone Number
_________________________________________________________
_________________________
E-mail Address
Facsimile Number
If the claimant is represented by an attorney, please complete the following section, and
attach a copy of the Power of Attorney:
_________________________________________________________
________________________
Name of Attorney
State Bar No.
_________________________________________________________
________________________
Name of Law Firm
Tax ID Number
_________________________________________________________
________________________
Street Address
Telephone Number
_________________________________________________________
________________________
City
State
Zip
Facsimile Number
_________________________________________________________
E-mail Address
Gramercy Insurance Company Proof of Claim
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