Claimant Information

If you are a Settlement Class Member as defined on page 2 of the Notice of Proposed Partial Class Action Settlement, Settlement Hearing and Right to Appear (“Notice”) with respect to the purchase of insurance coverage from the Defendants described on page 2 of the Notice where the coverage incepted or renewed during the period January 1, 1997, through March 25, 2019, you must complete the following form for each such insurance that you purchased or renewed and mail it to the address listed above in order to participate in the Settlement for such policies. You may also complete the form online at This claim form must be postmarked or submitted online by October 25, 2019.

Policy Information

Must click Add Broker Policy Information to submit your policies.

Lloyd's Name Policy Number Total Paid Policy Date Broker Name Broker Address Broker City Broker State Broker Zip Code Broker Phone Number Action


All information submitted in a Claim Form and in support of a Claim Form is subject to further inquiry and verification. The Claims Administrator may ask you to provide additional supporting information or documentation. Failure to provide such requested information or documentation might adversely affect, or result in denial of, your claim.

In addition to the signed and dated online Claim Form you are submitting here, you may also submit any documentation you have in support of your claim. Receipts, policy documents, or similar records are preferred. If you do not have your original policy information, you may include a signed statement regarding the Lloyd’s policies you purchased or renewed, the year the policies were in effect, and the approximate amount of the annual premiums you paid for each policy. You must sign and date any statement you provide, as it will be deemed submitted as true and correct under the penalty of perjury. The submission of false information may subject you to civil and/or criminal penalties.

Any supporting documentation should be submitted as legible copies.

Please use the browse option, by clicking on “Select Files” in the box below to upload your supporting documentation.

Files To Be Uploaded Size 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.