Lighthouse Excalibur Insurance Company Proof of Claim Form

LIGHTHOUSE EXCALIBUR INSURANCE COMPANY
PROOF OF CLAIM FORM (POC)

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

NOTICE TO VENDORS, AGENTS/PRODUCERS, BROKERS AND GENERAL CREDITORS OF LIGHTHOUSE EXCALIBUR INSURANCE COMPANY

CLAIM FILING DEADLINE September 23, 2022

The Louisiana Commissioner of Insurance (as Liquidator) has been directed by Court Order dated May 23, 2022, to liquidate Lighthouse Excalibur Insurance Company (LEX). 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 LEX, 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. CDT on September 23, 2022 (Claim Filing Deadline) in order to participate in the distribution of assets of LEX.

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.

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: 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 (September 23, 2022 at 4:30 p.m. CDT).

5. Payment: After all claims against LEX 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 # (LEX#####) 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 Lighthouse Excalibur Insurance Company, you may contact your legal counsel (if represented) or the Receiver’s office at:

Lighthouse Excalibur Insurance Company in Liquidation
9543 Fenway Ave.
Baton Rouge, LA 70809
Email POC@RecLA.us
Must include submission ID#(LEX#####) and name

Claimant Name (Company or individual authorized to receive POC payment)*

Contact Name*

First NameLast Name

Mailing Address*

Mailing Street Address

Mailing Address Line 2

CityState

Postal / Zip Code

Email*

example@example.com

Confirm Email*

example@example.com

Alternate Email

example@example.com

Phone Number*

Please enter a valid phone number.

Alternate Phone Number

Please enter a valid phone number.

Taxpayer ID

Type of Claim*

Agent ClaimGeneral Creditor Claim (claim for adjuster's fees, legal fees, membership fees, subscription agreements, marketing services, etc.)Secured Claim (claim secured by a mortgage, trust, deed, security agreement, etc. and additional documentation of security must be provided)Reinsurance ClaimEmployee Claim (limited to $2,500)Federal Government or State Agency ClaimAll Other Claims

**Policyholders do not need to file a POC Form, please file your claim by the claim filing deadline with your state's guaranty fund.**

Amount of Claim*

Enter the amount owed to you. Prior payments, offsets, counterclaims, and defense to the claim should be deducted from the Amount of Claim.

Provide a brief description of your claim.*

List any prior payments made on the debt (if applicable). Include date and payment amount.

List/describe any offsets, counterclaim or defenses to the debt.

Examples include: secured loans, lease agreements, commissions, etc.

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.

Attach Supporting Documentation Here

If you have any issues uploading your supporting documents, please email POC@RecLA.us with your submission ID # (LEX#####) and name in the subject line.

Please indicate the number of files uploaded as supporting documentation. *

Are you represented by legal counsel?

YesNo

Please provide the attorney's contact information.

Attorney Name

Attorney Phone Number

Please enter a valid phone number.

Attorney Mailing Address

Mailing Street Address

Mailing Address Line 2

CityState

Postal / Zip Code

Attorney Email

example@example.com

Confirm Attorney Email

example@example.com

Select the status of your claim

Claim is based on a court judgment or settlement. Please attach copy if applicable.Claim is currently pending in court. Please provide details and documentation if applicable.Claim has not been filed in court.

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 LEX. 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 # (LEX#####) 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.

Type Your Signature Below*

By typing your name above, you are agreeing that your typed named acts as an electronic signature and is the legal equivalent of your manual signature on this Proof of Claim Form.

Title (if for business)

Date*

Date

ANY CLAIMS SUBMITTED AFTER THE CLAIM FILING DEADLINE (SEPTEMBER 23, 2022 at 4:30 P.M. CDT) 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.

Proof of Claim (POC) Form General Instructions