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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.
Claims Intake Sheet Form

Intake Sheet

Today's date:
Name of person completing form:
Primary contact:
Firm name:
Policy number:
Phone number:
Email address:
Claimant name:
Client(s) name:
  
Length of relationship:

Type of services rendered:
Date of notice:

How notified:
Complaint/Summons          Attorney Letter          Verbal
Regulatory Agency          No Entry/Other         
Self Detected          Client Letter           

If Subpoena - Type of subpoena:
Testimony          IRS Summons          Trial
Documents          Grand Jury         
Other
Date Subpoena served:          Date action required:

Summary of facts:



Supporting documents pertaining to this matter available:     If available, they will be requested at a later time.
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       Copyright 2010 CAMICO Mutual Insurance Company. All rights reserved.  
       Coverage for the CAMICO program is provided by (i) CAMICO Mutual Insurance Company;
       (ii) Liberty Insurance Underwriters Inc., administered by CAMICO Insurance Services.
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