NORTH CAROLINA SELF-INSURANCE SECURITY ASSOCIATION

                                                 P.O. Box 12442

                                          Raleigh, NC 27605-2442

PROOF OF CLAIM

Name of Claimant: ____________________________________________________________________________

Address: ____________________________________________________________________________________

Amount of Claim: _____________________________________________________________________________

Date of Injury: ________________________________________________________________________________

Date(s) of Service: _____________________________________________________________________________

Date of Insolvency: _____________________________________________________________________________

Description of Claim (Written documentation including the basis for the transfer of Claim):

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

This claim has not been paid as of the date of this Proof of Claim: __________________________________________

Any setoffs or other series of payment for this Claim: ___________________________________________________

_____________________________________________________________________________________________

Undersigned subscribes and affirms as true under penalties of perjury as follows: that he or she has read the foregoing
Proof of Claim and knows the contents thereof to be true to the best of his or her knowledge or belief, that the
Proof of Claim represents a “covered claim” under the North Carolina Security Act pursuant to N.C. Gen. Stat. § 97-130
in the amount of _______________________________ Dollars ($____________) and that the undersigned is
authorized to make this claim. At any time the North Carolina Self-Insurance Security Association may request the
Claimant to present information or supplemental documentation.

CLAIMANT’S NAME: _______________________________________________________________________

(Please print or type)

BY: ______________________________________________________________________________________
                                                                  (Signature and Title of Claimant/Duly Authorized Individual)

DATE: ___________________________________________________________________________________

ADDRESS: ____________________________________________________________________________

TELEPHONE: _____________________________________________________________________________

SOCIAL SECURITY NO or EMPLOYER I.D. NO. ___________________________________________________

                                                               RETURN ORIGINAL AND ONE COPY TO:

                                         NORTH CAROLINA SELF-INSURANCE SECURITY ASSOCIATION

                                                              P.O. Box 12442, Raleigh, N.C. 27605-2442.

                                                   PLEASE RETAIN ONE COPY FOR YOUR RECORDS.

           A PROPERLY FILED PROOF OF CLAIM INCLUDES A STAMPED
                                        SELF-ADDRESSED ENVELOPE.

FOR OFFICE USE ONLY:

Date Received: _______________________________________

Claim Number: _______________________________________

Total Amount Claimed: ________________________________

Previous Payments Received: __________________________

Amount Now Claimed: ________________________________