Intake Sheet
* Required Fields
Today's date:

Name of person completing form: *

Primary contact: *

Firm name: *

Policy number:
Phone number:
Email address:

Claimant name and address:
Client(s) name:

Length of relationship:
Type of services rendered and the damages that may result:
Date of notice: *
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How notified:
 Complaint/Summons
 Regulatory Agency
 Self Detected
 Attorney Letter
 No Entry/Other
 Client Letter
 Verbal
If Subpoena - Type of subpoena:
 Testimony
 IRS Summons
 Other
 Documents
 Grand Jury
 Trial

Date Subpoena served:
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Date action required:
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Explanation of why the Claim was made or why the Potential Claim may become a Claim: *

Supporting documents pertaining to this matter available:
    If available, they will be requested at a later time.


REPORT A CLAIM OR POTENTIAL CLAIM

If you have a circumstance that your firm would like to report, please complete the Claims Intake Form below. A CAMICO representative will contact you within 1-2 business days. If this is an urgent matter, please call CAMICO at 1.800.652.1772 and request to speak with a Claims representative.

Please note: The Intake Sheet is to report new matters only. You do not need to complete the Intake Sheet for existing matters that have already been reported to CAMICO. Please contact the Claims Department at 1.800.652.1772 for questions on open/existing matters. Thank you.