Can I e-sign this form?

Yes. Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure the signer demonstrates intent, consents to electronic records, the signature is attributable, and the record can be retained or reproduced.

Do I need a notary or witnesses?

Most claim forms do not require notarization or witnesses. If the form includes an affidavit or the filing authority requires a notarized statement, follow that requirement. Notarization rules and RON availability vary by state.

What supporting documents are typical?

Common attachments include photos, invoices or receipts, police or incident reports, medical bills, and proof of ownership. Label files clearly and include dates and a short description for each attachment.

How do I correct a submitted form?

Contact the receiving office immediately. If allowed, submit an amended form clearly marked as an amendment and include the original submission date. Keep a copy of both versions and any confirmation receipts.

How long must I retain claim records?

Retain records during the active claim and for applicable post-closure periods. Follow federal rules such as IRC §6501(a) for tax records and HIPAA 45 CFR §164.530(j) for healthcare documents as applicable.

What security or compliance should the eSignature vendor provide?

Look for TLS 1.2/1.3 and AES-256 encryption, SOC 2 Type II, ISO 27001, ESIGN/UETA compliance, and a signed BAA for HIPAA-covered data. Vendor plan names commonly include Business, Business Premium, Enterprise, and Site License options.

Electronic Signature
Templates
Insurance
California Claim Form

California Claim Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

CLAIM FORM

Mail To:

PG&E Law - Claims Dept.

1850 Gateway Blvd. 6th Floor

Concord, CA 94520-OR

Email to: LawClaims@pge.com -OR- Fax to: 925-459-7326

Helpline phone: 415-973-4548

62-1444
Rev 2/2011

PLEASE PRINT

Title

AM PM Location of Incident (check if same as mailing address)

Description of Incident

PROPERTY DAMAGE: Attach repair estimates, invoices, proof of purchase, or supporting documents. (Do Not Send Originals).

FOOD SPOILAGE: Include a separate itemized list of each item of food spoiled and documentation of cost.

NOTE: Under California damages law you are entitled to reimbursement for the lesser of fair market value or the cost to repair your damaged property. We use the replacement cost of the item and depreciate that amount to arrive at the fair market value. You may consider consulting with your insurance carrier.

Item Description	Make/Brand	Model: Name / Number / Size	Age	Amount Claimed

Total Amount Claimed

Were you injured? Yes No

Other Losses (lost wages, lost revenue, medical expenses, etc.) Use Additional paper if necessary

Witnesses: Name, Address, and Telephone

PG&E Employee Other

I understand that Pacific Gas and Electric Company will review all documentation in support of this claim. I certify that the foregoing is true and correct.

Prepared By

Relationship to Claimant

Signature

Date

CLAIMS PROCESS

We understand you have sustained a loss and you believe PG&E may be responsible. If we prove to be responsible, we want to promptly and fairly compensate you. To evaluate your claim, we must determine how the incident happened, whether or not we caused it, and compensate you fairly under the law. Below are some frequently asked questions about submitting a claim to Pacific Gas and Electric Company.

WHAT IS THE CLAIMS POLICY AND PROCESS? It is PG&E’s policy to respond to claims promptly and fairly. We evaluate each claim based on the information you provide and our investigation. The time to investigate your claim will depend on the information you provide and the complexity of the incident. Our goal is to reach a decision on your claim within 30 days of its receipt. However, if there are complex issues involved, or if we need additional information, the process may take longer.

WHO IS RESPONSIBLE FOR DAMAGES? Generally speaking, PG&E is responsible for damages that result from its negligence. If any person, business or property is damaged because PG&E does something unreasonable, or because we unreasonably fail to do something that should have been done, then we are obligated to reimburse reasonable damages. We are not responsible for damages that we do not cause or that are the result of forces beyond our control. For example, in most instances we are not responsible for power outages or voltage fluctuations caused by earthquakes, weather conditions (such as lightning, floods, heavy storms, extreme heat or winds) curtailments or outages initiated at the direction of any electric grid operator or due to a failure of gas supplies not caused by us. There may be situations in which PG&E is only partially responsible for a loss. In those cases we will offer to pay our fair share.

WHAT IS YOUR RESPONSIBILITY? You have a duty to mitigate your damages, which means that you have to minimize the loss, and to make sure that losses or expenses incurred because of an incident are not accumulating needlessly and that they are reasonable in relation to the loss.

WHAT DO YOU NEED TO PROVIDE? You should retain copies of all receipts so you can provide full and accurate documentation of your losses or damages. You can help us expedite your claim by completing the claim form as thoroughly as possible, and by enclosing appropriate photographs and supporting documentation. Below are general examples.

Property Damage	Personal Injury*	Lost Wages	Business Losses	Miscellaneous Losses	Food Spoilage**
Detailed repair estimates	Date of Birth	Amount of time off	Tax records	Hotel receipts	Itemized purchase receipts
Detailed repair invoices	Gender	Employer’s verification	Bank statements	Restaurant receipts	Itemized list of cost and type of food
Purchase receipts	Treatment bills	Payroll stubs	Payroll records	Car rental receipts	List to identify if items were frozen or refrigerated
Appraisals	*Treatment records		Revenue statements	Expense statements
Photographs	Prescription receipts			Sales Receipts	Photographs
Rental receipts

*For personal injury losses, be prepared to provide your Social Security Number and to approve PG&E’s request for records from your medical provider(s).

**Food spoilage claims are evaluated based on the recommended guidelines from the US Department of Agriculture:

1. A fully stocked freezer will usually keep food frozen for 2 days after losing power, if the door remains closed.

2. A half-full freezer will usually keep food frozen about 1 day, if the door remains closed.

3. Food will usually stay cold in the refrigerator up to 4 hours, if the door remains closed.

WHAT ARE YOUR CLAIM OPTONS? You may wish to refer your claim to your insurance company, which may be able to reimburse you without an investigation and, depending on your coverage, may pay replacement values for damaged items. Your insurance company will seek reimbursement from PG&E.

WHAT IF YOUR CLAIM IS DENIED? If your claim is denied, we will send a letter explaining the reason. It may be because of a gas or electric rule that applies to your situation. These rules are on file with the California Public Utilities Commission (CPUC). They have the same effect as other laws. If you are not satisfied with our decision and explanation, you have the right to file a court action, including a small claims action. The small claims court hears matters not exceeding $7,500. The small claims process does not involve attorneys.

IS THERE A TIME LIMIT ON FILING A CLAIM OR A COURT ACTION? It is always best to submit a claim as soon as possible. PG&E is guided by claims experience and applicable time limits for filing legal actions, if the claim is denied. Our experience indicates that food spoilage and similar claims should be made promptly, and, therefore, such claims will only be paid if they are submitted and resolved within one year from the date of the incident. If you wish to file a court action, there are various time limits set by California law. Generally, these are: personal injury, 2 years from the date of the injury; personal inconvenience (such as a meal out), 1 year; business interruption or economic loss with no property damage, 2 years; tangible property damage, 3 years. If you have questions regarding these limits, you should consult an attorney.

WHAT IS THE ROLE OF THE CALIFORNIA PUBLIC UTILITIES COMMISSION (CPUC)? The CPUC sets general rules relating to claims process, but it does not rule on the underlying merits of a claim. If you have a billing dispute that you are unable to resolve with PG&E personnel, the appropriate remedy is to file a complaint with the CPUC. For further information about the role of the CPUC, you can call 800-649-7570 or visit its website at www.cpuc.ca.gov.

What the California Claim Form Is and when it applies

A California Claim Form is a standardized document used to assert a legal, insurance, administrative, or contractual claim within California. It collects claimant identity, incident or loss details, supporting evidence, requested relief or payment amounts, and the claimant's signature. Depending on context the form may be used for insurance claims, administrative benefit claims, small claims court notices, or vendor/service dispute submissions. Electronic completion and electronic signatures are permitted under federal and state law — generally governed by the ESIGN Act (15 U.S.C. ch. 96) and California's adoption of UETA — except where statutes expressly require paper, notarization, or wet signatures.

Why a correct, complete California Claim Form matters

Completing the form accurately reduces processing delays, preserves legal rights, and documents the elements of your claim for insurers, agencies, or courts. Proper attachments and clear signatures help avoid denials or procedural dismissals.

Who prepares and receives California Claim Forms

Typical parties include claimants, claims representatives, attorneys, and administrative or court clerks who intake, review, and decide claims.

Individual claimants and consumers who suffered loss, injury, or contract breach and need to document a claim in California.
Insurance adjusters, benefits administrators, or agency intake staff who review evidence, request additional documentation, and determine entitlement.
Attorneys, paralegals, and authorized representatives who prepare, file, or appeal claims on behalf of clients.

Role clarity helps assign responsibility for accuracy, supporting documents, and timely submission—especially when electronic signatures or third-party representatives are involved.

Step-by-step: filling out a California Claim Form

Follow a consistent order to gather information, complete the form, attach proof, sign, and submit to avoid processing delays.

01

Gather documents: Collect IDs, policy or contract numbers, photos, receipts, and police or incident reports.
02

Fill claimant details: Enter full legal name, contact, and preferred mailing address accurately.
03

Describe the loss: Provide incident date, location, concise narrative, and affected items or injuries.
04

Sign and submit: Sign in the signature block and send to the insurer, agency, or filing office per instructions.

Typical routing and decision flow after submission

Understanding the common routing steps helps set expectations for review, evidence requests, and final determination.

Submission: Claim sent to insurer, agency, or court clerk per instructions.
Intake review: Staff check completeness and request missing documents if needed.
Adjuster or adjudicator review: Fact development and liability or coverage determination occur.
Notice of decision: Claimant receives approval, payment details, denial, or appeal instructions.

How to configure an online claim workflow

Key digital settings help ensure secure collection, conditional fields, and timely notifications when using an eSubmission process.

Field	Configuration
Authentication	Email + optional SMS code for signer verification
Field types	Text, date (MM/DD/YYYY), currency, attachments
Conditional logic	Show supporting-file prompts when certain answers are selected
Notifications	Automated email/SMS on submit, status change, or missing info

Technical and interoperability considerations for eSubmission

Choose a platform that supports common file formats, secure transport, and your required authentication level.

Supported formats: PDF, DOCX, JPEG, PNG; preferred submission is a flattened PDF with attachments.
Integrations: Connectors to CRM, case management, or cloud storage (Salesforce, NetSuite, Google Workspace) aid processing.
Security: Use TLS 1.2/1.3 in transit and AES-256 at rest for document protection.

Ensure the chosen workflow logs audit trails (timestamps, IPs) and preserves a reproducible record for disputes or audits.

Timing expectations and statutory considerations

Different deadlines apply: policy-specific notice windows, administrative appeal periods, and statute of limitations that affect enforceability.

Notify insurer promptly:

Most policies require notice as soon as reasonably possible; check your policy language for precise timing.

Claim evaluation window:

Insurers commonly acknowledge and begin review within 30–45 days after complete submission.

Appeal timelines:

Appeal or reconsideration deadlines often range from 30 to 60 days after denial—verify your denial notice.

Statute of limitations:

Personal injury claims in California typically follow Cal. Code Civ. Proc. §335.1 (two years); verify the statute applicable to your claim.

Document retention:

Keep copies until resolution plus the applicable retention period for records and audits.

Penalties and legal risks of incorrect or false claims

Claim denial: Incomplete or inconsistent information may result in denial of benefits or payment.

Delayed payment: Missing evidence or errors can materially delay processing and settlement timelines.

Regulatory fines: Submitting false information can trigger administrative penalties under insurance or agency rules.

Civil liability: False statements may expose the claimant to perjury or fraud claims in civil court.

Criminal exposure: Intentional fraud in claims may result in criminal prosecution under state or federal statutes.

Statute loss: Late filings may forfeit the right to sue if the statute of limitations expires.

Common mistakes to avoid when preparing a claim form

Submitting incomplete contact or ID information that prevents verification and halts processing.
Attaching unreadable or unorganized evidence; label files clearly and include captions for photos and documents.
Using informal descriptions or estimates without supporting receipts, invoices, or professional appraisals.
Failing to sign, date, or indicate representative authority when a third party files on your behalf.

eSignature vendor comparison for filing and signing the California Claim Form

Cost and feature differences matter for high-volume claim workflows; signNow is listed first for comparison with common alternatives.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	No	No	Yes, limited	Yes, limited
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently asked questions about completing and eSigning a California Claim Form

Answers cover eSignature validity, notarization, required attachments, correction processes, retention, and platform compliance for California filings.

Need help? Contact support

Can I e-sign this form?
Yes. Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted. Ensure the signer demonstrates intent, consents to electronic records, the signature is attributable, and the record can be retained or reproduced.
Do I need a notary or witnesses?
Most claim forms do not require notarization or witnesses. If the form includes an affidavit or the filing authority requires a notarized statement, follow that requirement. Notarization rules and RON availability vary by state.
What supporting documents are typical?
Common attachments include photos, invoices or receipts, police or incident reports, medical bills, and proof of ownership. Label files clearly and include dates and a short description for each attachment.
How do I correct a submitted form?
Contact the receiving office immediately. If allowed, submit an amended form clearly marked as an amendment and include the original submission date. Keep a copy of both versions and any confirmation receipts.
How long must I retain claim records?
Retain records during the active claim and for applicable post-closure periods. Follow federal rules such as IRC §6501(a) for tax records and HIPAA 45 CFR §164.530(j) for healthcare documents as applicable.
What security or compliance should the eSignature vendor provide?
Look for TLS 1.2/1.3 and AES-256 encryption, SOC 2 Type II, ISO 27001, ESIGN/UETA compliance, and a signed BAA for HIPAA-covered data. Vendor plan names commonly include Business, Business Premium, Enterprise, and Site License options.

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