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THE UNITED STATES VIRGIN ISLANDS 
OFFICE OF THE LIEUTENANT GOVERNOR   
 
 
          DIVISION OF  
BANKING, INSURANCE  
AND FINANCIAL REGULATION 
 
PROOF OF CLAIM FORM 
IN THE MATTER OF 
REAL LEGACY ASSURANCE COMPANY, INC. 
 
 
 
This form must be prepared in duplicate, notarized and filed with the Office of the Lieutenant 
Governor, Division of Banking, Insurance and Financial Regulation at one of the following 
addresses. Please note that execution of this form does not entitle you to receive payment.  A 
determination on whether you are entitled to receive payment including how much payment you 
will receive, given the amount of funds available, will be made after all of the information, 
including all supporting documentation, is reviewed. 
 
Nisky Center, 2nd Floor 
 
 
 
 
 
7 & 8 King Street, 3rd Floor 
St. Thomas, VI 00802  
 
 
 
 
 
Christiansted, VI 00820 
Telephone: (340) 774-7166  
 
 
 
 
Telephone: (340) 773-6459 
 
Insured/Policyholder:   
Policy No:  
Policy Period:  
Claimant:  
I.D. No.: and Type  
Date of Loss:  
Type of Claim: (Please check one)   Original  Supplemental  Unearned 
Premiums   Depreciation Holdback   Replacement check   Loss 
of use   Other 
  
  
I. POLICYHOLDER/CLAIMANT 
1.  Full Name: _______________________________________________________________ 
2.  Physical Address: Street ________________________________ Apt/Suite No.: ________ 
     City ____________________________, State _________________   Zip Code _________ 
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 3. Mailing Address: Street/P.O. Box ___________________________ Apt/Suite No.: ______ 
     City ___________________________, State _________________   Zip Code __________ 
 
4. Telephone No.: Home: ______________________, Work: __________________________ 
 
 
          Cell: ________________________, Fax: ___________________________ 
 
II. LEGAL REPRESENTATIVE 
1.  Full Name: _______________________________________________________________ 
2.  Physical Address: Street ________________________________ Apt/Suite No.: ________ 
     City ____________________________, State _________________   Zip Code _________ 
 
 3. Mailing Address: Street/P.O. Box ___________________________ Apt/Suite No.: ______ 
     City ___________________________, State _________________   Zip Code __________ 
 
4. Telephone No.: Home: ______________________, Work: __________________________ 
 
 
          Cell: ________________________, Fax: ___________________________ 
III. Each Proof of Claim form should be accompanied by all supporting documents that are 
in the possession of the claimant.  Supporting documents may include, but may not be 
limited to, policies, correspondence, bills, obligations, contracts, bonds complaints, 
judgments, estimates, photographs, damages, medical records, medical bills and/or 
evidence of out of pocket expenses, etc. 
 
(List the enclosed documents): 
 
 
 
 
 
 
IV. Claim is for: (Check all that apply) 
      Policyholders/Insureds: 
 Claim is made for a loss or occurrence arising under the coverage of the policy.   
 Claim is made for the return of unearned premium due to early cancellation. 
Was premium financed? Yes  No 
Amount of Premium/Consideration paid to date $______________ 
Amount of Claim: $________________ 
 
 
Claimants other than Policyholders/Insureds: 
 Claim is made against policyholder/Insured. 
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 Claim is made by an attorney for unpaid legal expenses. 
 Claim is made by an agent or broker. 
 Claim is made by a general creditor for unpaid invoices. 
 All other claimants. (On a separate sheet, describe nature of claim and consideration given 
for it.  Claim Amount $_____________________.) 
 
Answer the following if applicable: 
No part of the debt has been paid except: _________________________________________ 
 
 
 
There are no setoffs or counterclaims to the debt, except::____________________________ 
 
 
There is no Security for the debt, except:__________________________________________ 
 
 
 
Status of Claim: 
 Claim is based on a court judgment or settlement (attach order or agreement). 
 Claim is currently pending in court (provide details and documents). 
 Claim is not yet filed in court. 
 
The Ancillary Receiver’s acceptance of the Proof of Claim form is not intended to nor does it 
constitute any waiver or relinquishment by the Receiver of any defense, setoff or counterclaim that 
he/she may have against any person, entity or governmental agency. 
 
The undersigned subscribes and affirms as true, under penalty of perjury, under the laws of the 
United States Virgin Islands, the following: 
1. That he/she has read the foregoing Proof of Claim form and knows the contents thereof. 
2. That this claim is justly owing to the claimant. 
3. That the matters set forth above and in any accompanying documents are true to the best of 
his/her knowledge and belief. 
 
 
 
 
 
 
 
 
 
 
____________________________________ 
Signature of Claimant or 
Authorized Representative 
 
__________________ 
NOTARY PUBLIC