Utah Insurance Receivers Office

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The date of submission of all WCMIC Proofs of Claim has passed.  For any additional needs please contact the Utah Insurance Receivers' Office at 801-972-7500.  You may also send postal mail to 215 South State Street, Suite 300, Salt Lake City, UT 84111.

This is an online form to submit your Proof of Claim against Wasatch Crest Mutual Insurance Company in Liquidation electronically.  This web page is not secured and if you wish to maintain secure submission of the Proof of Claim data, please print the form from the link below and mail it in.  Some users may experience difficulty if using AOL as their internet browser/email service.  You may also have difficulty submitting the form if java script is not enabled within your browser.  If this is the case, click the link below to begin download of a Proof of Claim form to be mailed through a postal service to the Estate.  Instructions for filling out this form are available at the link below, which will open in a new window.  Please print the confirmation page that will display once you have submitted the form for your records!  Please contact the webmaster if you have any problems with these documents.  

 

1. Claim is made by secured creditor in the amount of
$ (please include decimal)
                or
2. Claim is made for benefits provided by a policy in the amount of
$
                or
3. Claim is made by an attorney for unpaid legal expenses in the amount of
$
                or
4. Claim is made by a general creditor for unpaid services or invoices in the amount of
$
                or
5. Claim is made by an agent or broker for unpaid commissions or invoices in the amount of
$

6. Claim is made by all other claimants in the amount of
$

TOTAL AMOUNT OF CLAIM  $

The Particulars of the claim:

The identity and amount of security if any on the claim:

If you have received any payment or compensation for your claim, please state identity and amount of payment received.

If you have assigned your right of recovery please indicate assignee's name and address.  A copy of assignment must be mailed to the Utah Insurance Receivers' Office address listed at bottom of page. 

CLAIMANT NAME AND ADDRESS                    NAME & ADDRESS OF ATTORNEY (IF ANY):
                   
CLAIMANT PHONE NUMBER                           ATTORNEY PHONE NUMBER  
                                       

The person described herein verifies and affirms that the amount claimed is justly owing and there is no setoff, counterclaim, or defense to the claim.

You may be required by the Liquidator to supply additional information in support of your claim.

 

Wasatch Crest Mutual Insurance Company in Liquidation
Utah Insurance Receivers Office
215 South State Street Suite 300
Salt Lake City, UT 84111
Phone (801) 595-8222
Revised: January 03, 2007