Only one Proof of Claim (POC) form must be completed as part of the submission of your master claim. In addition to the POC, you must complete an itemization table even if you have only one claim to submit. Please read and follow the directions below.
Please make sure the W9 form matches your billing information. Claims must be submitted by the entity who 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.
To properly complete and submit your All Other General Creditor Master Claim Itemization Table and imaged invoices, please carefully read and follow the instructions below.
STEP #1 Download the All Other General Creditors Master Claim Itemization Table from our website. If you are unable to download the form, you can create your own form on Microsoft Excel or Microsoft Access as long as it includes the headers below:
|a. Policyholder Name (if applicable)||d. Policy Cancel Date (Agents Only)|
|b. Policy # or Invoice #||e. Total Premium (Agents Only)|
|c. Policy Period or Date of Service||f. Amount Claimed|
Some of the headers may not apply to your situation. Please enter "n/a" if the header does not apply. Please do not delete any of the headers.
STEP #2 Create a consolidated * PDF file (Adobe.pdf) of all of the invoices listed on the All Other General Creditor Master Claim Itemization Table and any other supporting documentation as well images of any contracts, fee or commission schedules/agreement that existed between your organization and the company in Receivership. The images should be in the order listed, please. (* “Consolidated” means a scrollable collection of images.)
Note: Paper submission of bills is limited to 20 or fewer pages.
STEP #3 Copy (burn) the All Other General Creditors Master Claim Itemization Table and all imaged invoices and supporting documents to a CD and 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 the company who can answer questions regarding the master claim being submitted. Then mail the CD along with your completed proof of claim form to the following address:
Florida Department of Financial Services, Receiver
Attn: Claims Section Master Claims
325 John Knox Road
Atrium Building, Suite 101
Tallahassee, FL 32303
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.