PCI Theater Insurance Program

Property/Casualty Claim Form

The “submit form” button at the end of this page will email your claim directly to Ponta, Castle & Ingram Agency. It will give us enough information to file the claim on your behalf. Once filed, a claims adjuster will contact you. The adjuster may request more information from you in order to fully process your claim.

Please keep copies of written documents. Please keep notes. Contact PCI at 800-259-6720 for assistance.

DO NOT use this form to file a claim on your Volunteer-Accident Policy. You must file those claims directly to AIG as noted on your claim form that came with the policy.

CLAIM FORM DIRECTIONS:

1. Fully complete PART 1 for all claims.
2. Then complete either PART 2 (for a GL claim) or PART 3 (for a Property claim).

PART 1: GENERAL INFORMATION
(Information needed in order to file a claim)
Theatre Group Name:
Address:
City:
State:	(Choose One)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoVirgin IslandNorthern Mariana IslandsGuamAmerican SamoaOther
Zip:
Contact Name:
Contact Phone:
Date of Loss:
Loss Location Address:
Loss Location City:
Loss Location State:	(Choose One)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoVirgin IslandNorthern Mariana IslandsGuamAmerican SamoaOther
Loss Location Zip:
Was there a Police Report filed?	Yes No
If yes, provide File Number:
PART 2: GENERAL LIABILITY CLAIM
(Claim involves an Accident/Injury to a Patron)
Describe details of the accident (please be specific:
Name of Injured Party:
Injured Party Address:
Injured Party City:
Injured Party State:	(Choose One)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoVirgin IslandNorthern Mariana IslandsGuamAmerican SamoaOther
Injured Party Zip:
Injured Party Phone:
Was claimant transported to a hospital?	Yes No
If yes, please provide the name and address of the hospital:
Please provide the names & addresses of witnesses:
PART 3: PROPERTY CLAIM
(Claim involves damage to, or loss of, property)
Provide a narrative describing details of the loss (be specific):
Press “Submit Form” button to send the completed form to PCI. Please press only once, as this form may take a few moments to process.