Intake Sheet

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 800.652.1772 / 650.378.6800 and request to speak with a Claims representative.

Please note: For your protection California law requires the following to appear on this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. 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 800.652.1772 / 650.378.6800 for questions on open/existing matters. Thank you.