Form Gen-1720 Involuntary Unemployment Claim - Claims Service Center
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1
2
3INVOLUNTARY UNEMPLOYMENT CLAIM FORM
® INS URANCE COMPANY OF THE S OUTH
Claims Service Center
® LYNDON PROPERTY INS URANCE COMPANY
P.O. Box 45153 / Jacksonville, Florida 32232-5153
® LYNDON S OUTHERN INS URANCE COMPANY
Fax 904-355-5878
® AMERICAN GUARANTY INS URANCE COMPANY
Toll Free 1-800-888-2738, Ext. 8303
This form must be completed in full and submitted with the following:
1. A copy of the loan agreement
2. A copy of the Involuntary unemployment certificate of insurance
3. A copy of the State Unemployment Benefit Payment History
Claimant’s Name:
__________ _______
Creditor Name:
__________________________
Claimant’s Address:
Address:
________
________
Telephone Number:
________
Agency Code Number:
Email Address:
____________
Loan Number:
Signature / Title
Date
S TATEMENT OF THE INS URED: ITEMS 1 THRU 10d. ARE TO BE COMPLETED BY YOU THE INS URED
– HOW TO FILE YOUR CLAIM –
A.
Submission of an incomplete or unsigned form may result
C.
Have Section II completed by the State Unemployment
in a delay in processing your claim.
Office which is handling your claim.
B.
Type or print all entries.
D.
Have Section III completed only if you are not registered
with the State Unemployment Office.
SECTION 1
INSURED’S STATEMENT
1.
Claimant’s Name
2.
Address
3.
City, State & Zip Code
4.
Home Telephone No. (
)
5.
Date of Birth
/
/
6.
Social Security Number
7.
Last Date Employed
7a. Number of hours worked per week
8.
On what date do you expect to return to work
9.
Last Employer
9a. City, State & Zip
9b. Business Telephone No. (
)
9c. Occupation
9d. Employed from
/
/
through
/
/
(if less than 12 consecutive months, prior to the loan effective date, please complete items 10 through 10d below)
10. Last Employer
10a. City, State & Zip
10b.Business Telephone No. (
)
10c. Occupation
10d. Employed from
/
/
through
/
/
GEN-1720 11-013895-11
Ed. 3-98
Rev. 5/2010
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