ERMA Initial Claim Report Form

In order to assist ERMA in monitoring claims and maintaining reserves, please fill out the following form for each claim or occurrence that is required to be reported to ERMA. Please answer each item as completely as possible with the information available to you. Use additional sheets as necessary. Please attach to this form a copy of all Governmental Tort Claim, DFEH and/or EEOC, and internal or external complaint/investigation documents you have regarding this claim or occurrence. Assignments to defense counsel will be made through ERMA after consultation with the ERMA member. If you have any questions, please call the ERMA office at (800) 541-4591.

Please enter the information of the person submitting this form below:

Name*

Title*

Email Address*

Phone Number*

Claim Information

Date of Report*

Name of Entity*

Name(s) of Claimant*

Claimant's Job Title

What is the Claimant's employment status? (mark all that apply)

Date of Termination (if applicable)

Date of Hire

Claimant's Annual Salary Amount ($)

Complaint submitted?*

Yes
No

Date Complaint Submitted

If written, please provide date of complaint and attach a copy. If verbal, please provide date and name/title of the person the complaint was reported to

Name and job title of person complaint reported to:

CRD complaint filed?*

Yes
No

Date of CRD filing:

Date of CRD Right to Sue Letter (if received)

EEOC complaint filed?*

Yes
No

Date of EEOC filing:

Date of EEOC Right to Sue Letter (if received)

Was a Governmental Tort Claim filed?*

Yes
No

Date of response to tort claim (if received)

Date of first incident underlying the complaint:

Brief factual summary

Demand by Claimant

What is the Demand by Claimant?

File

Max. file size: 50 MB.

If you have any questions regarding reporting to ERMA, please email Stacey Sullivan at [email protected]