LIGHTHOUSE HOLDINGS GROUP, LLC
PROOF OF CLAIM FORM (POC)

James J. Donelon, Commissioner of Insurance vs
LIGHTHOUSE HOLDINGS GROUP, LLC
DOCKET NUMBER 717,274, Section 26
19th JUDICIAL DISTRICT COURT OF THE STATE OF LOUISIANA,
PARISH OF EAST BATON ROUGE

NOTICE TO CREDITORS AND VENDORS OF
LIGHTHOUSE HOLDINGS GROUP, LLC

CLAIM FILING DEADLINE DECEMBER 15, 2022  

The Louisiana Commissioner of Insurance (as Liquidator) has been directed by a Court Order dated August 15, 2022 to liquidate Lighthouse Holdings Group, LLC (LHG). A copy of the Liquidation Order may be found at http://www.Lighthouse.Insurance.

The Liquidation Order requires that any person having a claim or claims against LHG, its property, or its assets, to present their claim(s) to the Receiver by a properly completed Proof of Claim on or before 4:30 p.m. CST on December 15, 2022 (Claim Filing Deadline) in order to participate in the distribution of assets of LHG.

If you have a claim, you must fill out this form and return the form to the Receiver no later than the Claim Filing Deadline indicated above. You must file a separate Proof of Claim (POC) for each type of claim or for multiple claims of the same type. Failure to complete and return this form to the Receiver by the Claim Filing Deadline may result in your claim being treated as a late-filed claim.

1.     Completing the Proof of Claim Form:  In order to have your claim considered, please type your information in the appropriate fields below. Failure to complete the required fields will result in the non-admission of your form. A separate Proof of Claim Form should be submitted for each Type of Claim. DO NOT PRINT AND MAIL THIS FORM. THE POC FORM MUST BE SUBMITED THROUGH THIS WEBSITE FOR TRACKING PURPOSES AND FOR THE ASSIGNMENT OF A POC TRACKING NUMBER. Upon submission you will be assigned a POC tracking number (LHG#####).  

 2.     Supporting Documentation:  To evaluate your claim, the Receiver requires documentation that supports your claim. When you submit your completed Proof of Claim Form, please provide a brief explanation of the claim, the amount claimed, and all documentation that supports your claim. Examples of the types of supporting documentation that should be submitted include the following:  invoices, agreements, evidence of payment, receipts, etc. Once you have completed and submitted your Proof of Claim Form, you should download and save the completed Proof of Claim Form and all supporting documentation for your records.

 3.     Request for Taxpayer Identification Number: If any part of payment of your claim would constitute rent, salaries, wages, annuities, compensations, remunerations or other fixed or determinable gains, profits, and income to you, please fill out an Internal Revenue Service Form W-9 and submit it with your completed Proof of Claim Form. A W-9 Form can be downloaded from the Internal Revenue Service website at www.irs.gov. The request for your Taxpayer Identification Number on the Form W-9, is authorized by 26 U.S.C. s. 6041 and related IRS regulations. Your Taxpayer Identification Number may be used to report claim payments made to the U.S. Internal Revenue Service. Your failure to provide a Taxpayer Identification Number may result in additional “Backup Withholding” on payments made to you and may subject you to penalties by the Internal Revenue Service. Your Taxpayer Identification Number may also be used for any other purpose specifically required or authorized by state or federal law.

 4.     Your Proof of Claim Form must be SUBMITTED on or before the Claim Filing Deadline of December 15, 2022 at 4:30 p.m. CST.

 5.     Payment:  After all claims against LHG are evaluated and approved by the Court, payment on approved claims will be distributed in accordance with priorities set by the laws of the State of Louisiana based on available funds. The Receiver will not know the percentage that can be paid on any individual claim until all liabilities are determined. This process may take several months or years after the deadline for filing claims has passed.

 6.     Change of Name or Address:  If you have a change of address after you submit your Proof of Claim Form to us, it is your responsibility to notify the Receiver in writing or via email that your address has changed. Some liquidations may take several years to conclude; therefore, you must keep the Receiver advised of your current address. This can be done by emailing the updated information to POC@RecLA.us with your submission ID # (LHG#####) and name in the subject line. 

IMPORTANT INFORMATION:  THE INFORMATION YOU PROVIDE ON THIS PROOF OF CLAIM FORM MAY BE SHARED WITH A THIRD PARTY FOR THE PURPOSE OF EVALUATING YOUR CLAIM OR OTHER INTERNAL LIQUIDATION OPERATIONS. THE RECEIVER BY CONTRACT REQUIRES ANY THIRD-PARTY CONTRACTOR TO MAINTAIN CONFIDENTIALITY REGARDING THE PERTINENT INFORMATION IN ITS POSSESSION.

FURTHER INFORMATION:  If you want further information about the liquidation proceedings of LHG, you may contact your legal counsel (if represented) or the Receiver’s office at:

Lighthouse Holdings Group in Liquidation
9543 Fenway Ave.
Baton Rouge, LA 70809
Email POC@RecLA.us
Must include submission ID#(LHG#####) and name

Attach any supporting documentation including invoices, agreements, evidence of payment, receipts, etc. Your documentation should support that your claim is justly owed; and clarify any offsets, counterclaim, or defense to the claim. Include all invoices to show detailed breakdown and balance of amount claimed. 

I swear or affirm that I am the Claimant referenced in the mailing address on this form and/or am authorized to sign this form on the Claimant’s behalf. I further swear under penalty of law that all information contained on this form, as well as all attachments, are true and correct to the best of my knowledge and that the Amount of Claim is justly owed by LHG. Should any of the information provided change, including the receipt of monies from other sources for the claim contained herein, I will immediately contact the Receiver via email and report the change(s). I understand that if my contact information provided herein changes, it is my obligation to provide updated information to the Receiver. I will do this by emailing the updated information to POC@RecLA.us with my submission ID # (LHG#####) and name in the subject line. I acknowledge that if I fail to provide such updated information, the Receiver will have no obligation to seek this updated information from any source.

ANY CLAIMS SUBMITTED AFTER THE CLAIM FILING DEADLINE (DECEMBER 15, 2022 at 4:30 P.M. CST) WILL BE CONSIDERED UNTIMELY AND INELIGIBLE FOR PAYMENT UNTIL AFTER ALL TIMELY FILED CLAIMS ARE PAID IN FULL.

Each Proof of Claim must have all supporting documentation attached to be considered.