Ucic Proof Of Claim Form - Delaware Department Of Insurance
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1
2PROOF OF CLAIM
_________
United Contractors Insurance Company,
POC Number
A Risk Retention Group, In Liquidation
(Official Use)
DEADLINE FOR FILING CLAIMS IS FEBRUARY 27, 2015
Please read the instructions carefully before completing both sides of this Proof of Claim form. Each section must be fully completed.
1. CLAIMANT’S NAME:____________________________________________________________________________________
2. MAILING ADDRESS:_____________________________________________________________________________________
3. TEL. NO. (Daytime):______________________________ 4. FAX NO.: _____________________________________________
5. E-MAIL ADDRESS:______________________________ 6. DATE OF LOSS:________________________________________
7. UNITED CONTRACTORS INSURED’S NAME:________________________________________________________________
8. CLAIM NO: ___________________________
9. POLICY OR CONTRACT NO.:_________________________________
10. TYPE OF POLICY OR CONTRACT:
A. ( )
Liability Insurance Policy
B. ( ) Commercial Automobile or Truck Liability Insurance Policy
C. ( ) Commercial Multiple Peril
D. ( ) Other---Please specify type of policy or contract:__________________________________________________________________
11. CLAIM IS FOR (Place an “X” by each one that applies; you may check more than one):
A. ( ) Claim by Policyholder for Policy Reimbursement for Claims.
B. ( ) Claim by Policyholder for Return of Unearned Premium.
C. ( ) Claim for Bodily Injuries and/or Property Damage Allegedly Caused by United Contractors' Policyholder
D. ( ) Workers compensation claim against United Contractors' policyholder
E. ( ) Claim by Reinsurer for Reinsurance Premium or Other Reinsurance Treaty Balances
F. ( ) Claim for Taxes and/or Interest/Penalty on Taxes
G. ( ) Vendor/ Other General Creditor
H. ( ) Other---Please explain the nature of the claim below or on an attachment (include claimant name on top of each page of attachment):
_______________________________________________________________________________________________________________
ATTACH ALL DOCUMENTATION SUPPORTING YOUR CLAIM TO YOUR PROOF OF CLAIM AND SUBMIT BY THE BAR DATE.
12. In the space below give a CONCISE STATEMENT of the FACTS giving rise to your claim. Attach additional sheets if necessary.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
13. AMOUNT OF YOUR CLAIM. $________________________________.
14. Is there OTHER INSURANCE which may cover this claim? YES (
). NO ( ). If YES, give name of the insurer(s) and policy number(s).
____________________________________________________________________________________________________________________
15. Are you REPRESENTED BY AN ATTORNEY: YES ( ). NO ( ). If YES, provide attorney’s name, address, telephone no. and email.
____________________________________________________________________________________________________________________
SEE REVERSE
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