ERMA Initial Claim Report Form

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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.
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    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
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