One Proof of Claim (POC) form must be completed to submit your master claim. Please read and follow the directions below.
Please make sure the W9 Form matches your billing information. Claims must be submitted by the entity that owns the Federal Tax Identification Number (FEIN) on file with the IRS. This means that if you bill under a FEIN that is assigned to an organization other than your facility, you must coordinate submission of your claim with the organization that owns the FEIN.
The total amount claimed on your Proof of Claim Form must equal the total amount claimed on your Master Claim Itemization Table. Below is a sample of how your completed Master Claim Itemization Table should look:
To properly complete and submit your Master Claim Itemization Table and imaged invoices, please carefully read and follow the directions below.
STEP #1 Download the Claims Vendor Master Claim Itemization Table from our website by clicking here. If you are unable to download the form, you can create your own form in Microsoft Excel or Microsoft Access as long as it includes all of the headers below:
|a. Insurance Company Claim or Policy #||f. Date Invoiced|
|b. Invoice or Reference #||g. Amount of Invoice|
|c. Claimant/Insured Name||h. Payments Applied|
|d. Date Assignment Received (Required)||i. Dates Payments Applied|
|e. Date Completed (if applicable)||j. Total Amount Claimed|
The Claims Vendor Itemization Table is provided as a Microsoft Excel Spreadsheet. If you do not have this program, you can download a free Microsoft Excel Viewer by clicking here.
TIP: Your accounting software may be able to produce a report with the same information required on the Claims Vendor Itemization Table which you can use as your itemization summary. As long as your report has the minimum detail shown in the table in Step #1 above, we will accept it as an itemization summary of your claim.
STEP #2 Create a consolidated * PDF file (Adobe.pdf) images of all the invoices listed on the Master Claim Itemization Table and the corresponding work product (estimate, summary report, signed appraisal award, etc..) in the order listed, please. (* “Consolidated” means a scrollable collection of images.) Also include an image of the applicable contract and fee schedule between your organization and the company in Receivership. For samples of acceptable invoices, please click here.
Note: Paper submission of bills is limited to 20 or fewer pages.
STEP #3 Copy (burn) the completed Claims Vendor Master Claim Itemization Table and all imaged invoices and supporting documents to a CD. Label the CD with 1) the name of your company (the claimant), 2) your RCN (unique number assigned to each claimant which appears on your Proof of Claim Form), and 3) the name, phone number and e-mail of a contact person at your company who can answer questions regarding the master claim being submitted. Mail the CD and completed Proof of Claim form to the following address:
Florida Department of Financial Services Receiver
Attention: Claims Section Master Claims
2020 Capital Circle SE, Ste 310
Tallahassee, FL 32301
Note: Claims submitted in a format other than what is specified may delay evaluation of your claim, result in the rejection of your claim in its entirety and/or require an offset against your claim for any administrative costs incurred.
Do you have questions?
Please see the contact information in the “Proof of Claim Form General Instructions” sheet on the back of the POC.