Proof of Claim Confirmation Form

SOUTHERN TITLE INSURANCE CORPORATION CLAIM CONFIRMATION FORM Case No. ICS-2011-00239, State Corporation Commission, Commonwealth of Virginia

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Claimant Information

Claim Number (Must match letter)

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

Name of Claimant: *

First

Last

Your Name *

First

Last

Address

Address Line 1

Address Line 2

City

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Zip Code

Email *

Facsimile Number:

Preferred Contact Method:

• Mail
• E-Mail

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.

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Date

Claimant: Claim Date

Signature

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