Syndicate Lloyds Settlement

Syndicate Settlement Claim Form

This is a new Claim.

This is a supplemental Claim to my claim filed in the prior Settlement.

Class Member Information

Claimant Name: *

Contact Title:

Company/Organization/Insured Name:

Street Address: *

City: *

State/Territory: *

Zip Code: *

Phone Number:

Email Address:

Policy Information

Please enter one policy per entry – click the ADD button below if you have multiple policies)

Name of Lloyd's Syndicate: *

Policy Number: *

Total Premium Paid: *

Date of Policy: *

Broker Name:

Broker Street Address:

Broker City:

Broker State/Territory:

Broker Zip Code:

Broker Phone Number:

Must click Add to save your information.

Name of Lloyd's Syndicate

Policy Number

Total Premium

Date of Policy

Broker Name

Broker Street Address

Broker City

Broker State/Territory

Broker Zip Code

Broker Phone Number

Action

I certify under the penalty of perjury that the information above is true and correct and that the submission of false information may subject me to civil and/or criminal penalties.

Your Signature: *

Title:

* Denotes required field