THEATRE INSURANCE
CLAIM FORM      ================================================================================

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

Keep copies of written documents. Keep notes.

Contact PCI at 800-259-6720 if you need assistance

DO NOT use this form to file a claim on your Volunteer-Accident Policy
6408-38-70. You must file those claims directly to the
Chubb office as noted in your insurance file.
 
 

COMPLETE PARTS [ 1 &2 ] or PARTS [ 1& 3 ]
[DEPENDING ON TYPE OF CLAIM]

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PART 1: GENERAL INFORMATION
[Information Needed in Order to File Claim]
 

1. Name & Mailing address of your theatre group:

2. Address of the Location where the incident occurred:

3. Name of contact person representing your theatre group:

4. Contact person's phone number:

 

PART 2: GENERAL LIABILITY CLAIM
[Claim Involves an Accident/Injury to a Patron]
 

1. Date of loss:

2. Name of injured person:

3. Address where loss occurred:

4. Describe details of the accident:

5. Was claimant transported to hospital? [If yes, include name & address of hospital]:

6. Name/address of injured  party:

7. Names/addresses of witness:

 

PART 3: PROPERTY CLAIM
[Claim Involves Damage to, or Loss of, Property]
 

1. Date of Loss:

2. Name of contact person representing theatre group:

3. Contact person's phone number:

4. Location of loss:

5. Provide a narrative describing details of the loss:

6. Police Report File Number. If you have not filed a police report, you must do so