Instructions For Proof Of Claim Form (Page 3 of 3) in pdf

Instructions For Proof Of Claim Form Page 3

Provide an explanation of your claim below. Attach additional pages if necessary.

NOTE: ATTACH DOCUMENTATION TO SUPPORT YOUR CLAIM

AFFIRMATION OF CLAIMANT

Unless noted herein: I alone am entitled to file this claim. No others have an interest

in this claim. No payments have been made on the claim. No third party is liable on

this debt. The sum claimed is justly owing, and there is no set-off. I declare, under

penalty of perjury, that all of the statements made in this Proof of Claim and all

documents attached to this form are true, complete, and correct. If I am making a

claim against a person insured by Gramercy Insurance Company, I understand that I

am waiving any right to pursue the personal assets of that person, to the extent of the

coverage and limits provided by the policy issued by the now insolvent insurer

Gramercy Insurance Company.

____________________________________

Signature

____________________________________

Print Name

State of

County of

The foregoing instrument was acknowledged before me this _________ day of

________________, 201__, by ________________________________, who has executed this

instrument on such individual’s own behalf, who is personally known to me or who has produced a

Driver License or other information as identification.

Notary Public

Printed Name

My Commission Expires:

(NOTARY SEAL)

Gramercy Insurance Company Proof of Claim

Page 2 of 2

Instructions For Proof Of Claim Form Page 3