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
Must include submission ID#(LEX#####) and name