Return Premium Form

If a recent insurance company insolvency is not on the list, Proof of Claim forms are not yet available. Please check again in 30 to 60 days. Information that is required is marked with a red asterisk*. The other information requested may be useful in processing your request.

Please select the option below, to identify*:

Insured
Broker
Finance Company

Your Name*:
DBA: (if applicable)
Street Address*:
City*:
State*:
Zip Code*:
Day Time Phone Number:

Please provide the following information, if available:

Your E-mail Address*:
	If you have an E-mail address, please provide in the box above. If you do not have an E-mail address, please answer with None.
Insured's Name
Street Address:
City, State & Zip Code:
Insured's Policy Number:
Effective Date of Policy:
Expiration Date of Policy:
Type of Policy:

Once you receive your proof of claim form, please see instruction below.
If you are a Finance Company:

Please include a copy of all original, signed finance agreements you wish to file a claim for when you return your proof of claim form.

If you are an Agent/Broker:

And you wish to file a claim for return premiums on an insured's policy, you must have an Assignment of Interest Form completed. You must also have filed your Proof of Claim form for commissions.

If you wish to print an Assignment of Interest form, Click Here.

This form may not be submitted electronically.

You must complete the Assignment of Interest Form, have signed by the insured and notarized, then mailed to this office. You may mail any complete Assignment of Interest Forms with your commission Proof of Claim form. If you have already filed your commission Proof of Claim form, the Assignment of Interest form may be submitted separately; however, no Assignment of Interest forms will be accepted unless the Agent/Broker has a timely filed commission Proof of Claim.

Office of the Special Deputy Receiver

Return Premium Form