Notice Of Claim Form
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1
2
3Notice of Claim
Commission Protection
Insurance
This form is provided for the reporting of Commission Protection claims pursuant to a Master Insurance Policy issued by certain
underwriters of Lloyd’s to the Real Estate Council of Ontario (RECO) and is without prejudice to the liability effected with Lloyd’s.
Please send this Notice of Claim and all attachments requested to the attention of:
ClaimsPro LP
Attention: Jan Perkins
16700 Bayview Avenue, Suite 211
Newmarket ON L3X 1W1
Phone: 1-877-740-1913
Fax: 1-866-735-1033
Email: claims@reco-claims.ca
Please note the following :
1. You should complete ONE (1) form for each trade
2. A failure to provide Lloyd’s with a properly completed form and/or supporting documentation may result in a
delay or possible denial of your claim.
CLAIM REPORTING FORM
RECO INSURANCE PROGRAM REGISTRANT INFORMATION
Name of Claimant (Registrant or Cooperating Brokerage)
Listing Brokerage
Cooperating Brokerage
Registration Number:
Residential Address:
Postal Code:
Telephone Number (Res.):
Cell Number:
Email Address;
Business Address:
Telephone Number (Bus.):
A. The Claimant(s) hereby applies for payment of a claim in the amount of : $
(net of HST and fee
split)
B. If you have received any payment or partial payment of commissions or advances please indicate amount $
___
C. Is the amount set out in B included in A ? Yes
No
2.
Identity of Brokerage and Broker Holding Claimant’s Deposit
Name of Brokerage:
Address of Brokerage:
Postal Code:
Telephone Number:
Fax Number:
RECO Insurance Program
Underwritten by certain underwriters at Lloyd’s
Endorsed by the Real Estate Council of Ontario
Distributed and Managed by Alternative Risk Services,
a division of 3303128 Canada Inc.
Lloyd’s CP Claim Form_01062015
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