SOUTHERN TITLE INSURANCE CORPORATION – In Receivership for Liquidation, Case No. ICS-2011-00239, State Corporation Commission, Commonwealth of Virginia

Who Should Submit

Claimants with approved Policyholder-level claims (“Claimant-Distributees”), or assignees of approved Policyholder-level claims (“Assignee-Distributees”) must submit both their completed claimant packet and a completed W-9 form. Claimants that assigned a portion of an approved Policyholder-level claim must submit a completed claimant packet. Multiple submissions for the same claim are not permitted.

If you have an approved Policyholder-level claim, you should have received a letter from Cantilo & Bennett, LLP, on behalf of the Special Deputy Receiver (the “Notice Letter”).

Submission Steps

1. Download Required Documents

Claimant Packets (select the one specified in your Notice letter)

Claimant-Distributee Packet (Hyperlink)

Assignee-Distributee Packet (Hyperlink)

Claimant-Assignor Packet (Hyperlink)

IRS Form W-9

Download W-9 (hyperlink)

2. Complete All Forms

Fill out the claimant packet and sign/notarize as required.

Complete and sign the IRS W-9 if you are a distributee.

3. Submit all documents

Upload them to this page together as a single submission (up to two files), or mail them to the address provided in your Notice letter.

Need Assistance?

Call Cantilo & Bennett, LLP at 512-478-6000 if you have not received your Notice Letter or have questions about completing or submitting the forms.

Submission

Claim Number (Must match Notice Letter)

Where would you like future correspondence and/or payment sent?

Submitter

Name of Claimant:

First

Last

Your Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Facsimile Number:

Preferred Contact Method:

Mail
E-Mail

Address Number Contact

Affirmation

Checkboxes

I am the claimant listed above. I have not assigned or transferred my claim against Southern Title Insurance Corporation to any other person or party.
I am the claimant listed above. I have assigned some or all of my claim against Southern Title Insurance Corporation to another person or party.
I am NOT the claimant listed above. I have been assigned some or all of the claimant’s claim against Southern Title Insurance Corporation.
N/A

If the claim has been assigned, upload documentation of the assignment below or email it to newclaims@southerntitle.com within seven days of submitting this form.

File Upload

Drag & Drop Files, Choose Files to Upload

Date

Signature (Type your full legal name):

The file size limitation for attachments is 128MB. If your attachments exceed this limit, please copy your documents to a CD or USB flash drive and refer to the Notice Letter and its instructions for submission by mail. If you have any questions or concerns, please contact the Cantilo & Bennett, LLP at 512-478-6000.

By submitting this form, I represent that I have legal authority to act for the Submitter named above.

I understand and agree that the knowing submission of false documents or abuse of this form is prohibited and may result in legal penalties.