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ERMA Initial Claim Report Form
Need Assistance?
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.
Date of Report
MM slash DD slash YYYY
Name of Entity
*
Name(s) of Claimant
*
Claimant's Job Title
What is the Claimant's employment status (mark all that apply)
current
terminated
paid leave
unpaid leave
suspended
Date of Termination (if applicable)
MM slash DD slash YYYY
Date of Hire
MM slash DD slash YYYY
Claimant's Annual Salary Amount ($)
Complaint submitted?
Yes
No
Date Complaint Submitted
MM slash DD slash YYYY
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:
MM slash DD slash YYYY
Date of CRD Right to Sue Letter (if received)
MM slash DD slash YYYY
EEOC complaint filed?
Yes
No
Date of EEOC filing:
MM slash DD slash YYYY
Date of EEOC Right to Sue Letter (if received)
MM slash DD slash YYYY
Was a Governmental Tort Claim filed?
Yes
No
Date of response to tort claim (if received)
MM slash DD slash YYYY
Date of first incident underlying the complaint:
MM slash DD slash YYYY
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]
Comments
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