Syndicate Settlement Claim Form

Class Member Information

Policy Information

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

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.

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