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:

Former Current

Length of relationship:

Type of services rendered and the
damages that may result:

*Date of notice:

Open the calendar popup.

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:

Open the calendar popup.

Date action required:

Open the calendar popup.

*Explanation of why the Claim was made or why the Potential Claim may become a Claim:

Supporting documents pertaining to this matter available:

YesNo 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.