In re:

PG&E CORPORATION,

- and -

PACIFIC GAS AND ELECTRIC COMPANY,

Debtors.

Affects PG&E Corporation

Affects Pacific Gas and Electric Company

Affects both Debtors

*All papers shall be filed in the Lead Case, 

No. 19-30088 (DM)

Bankruptcy Case

No. 19-30088 (DM)

Chapter 11

(Lead Case)

(Jointly Administered)

Omnibus Insurance Subrogation1 Proof of Claim

In part 2, questions 1 and 2, include the aggregate total amounts of all insurance subrogation claims for all liquidated, contingent or unliquidated 

insured losses held by the creditor(s) identified in part 1, question 2, of this Omnibus Proof of Claim.

Complete Attachment 1 to provide a detailed description of the Nature and Basis of this Omnibus Proof of Claim.

The filing of this omnibus, consolidated proof of claim is for convenience only and is without prejudice to any party in interest’s right to assert that 

the claim of each policy holder/tort victim to which the applicable insurer is “subrogated” (as that term is broadly defined herein) is a separate claim, 

or whether the undersigned creditor holds one single claim for purposes of these chapter 11 cases (including, without limitation, for voting 

purposes). All parties rights with respect to the foregoing are expressly preserved.

Signing this form constitutes an acknowledgement that you will provide additional support documentation to the Debtors upon reasonable request 

therefore, which support documentation shall be kept confidential and not filed with the Court unless under seal or with the express written consent 

of the undersigned creditor. 

Do not use this form to make a request for payment of an administrative expense or for general or priority claims that are not related to claims 

arising from any payment made or to be made by an insurer to or on behalf of a tort victim relating to a fire.

Filers must leave out or redact information that is entitled to privacy on this form or on any attached documents. 

A person who files a fraudulent claim could be fined up to $500,000, imprisoned for up to 5 years, or both. 18 U.S.C. §§ 152, 157, and 3571.

Part 1: Identify the Claim

1. Is this Omnibus Insurance 

Subrogation Proof of Claim 

being filed on behalf of one or 

multiple creditors? 

One creditor

More than one creditor 

2. Identify the creditor(s). For 

more than ten creditors, please 

attach a separate schedule. Name of creditor 1 Name of creditor 2

Name of creditor 3 Name of creditor 4

 

1 This form is for claims arising from or related to payments made or to be made by an insurer to or on behalf of parties insured under policies issued by such 

insurer who have, had or may have claims against the Debtors relating to the insured loss on account of which such payments were made, will be made or may 

be made (hereinafter, “tort victims”). Additional claims held by the undersigned creditor(s) may be separately filed. The use of the shorthand descriptive term 

“subrogation” herein is not intended to modify or limit the substantive rights of the holder of these claims or the basis for the claimant’s right to assert claims 

originating with insured tort victims. These “subrogation” claims include, but are not limited to, claims that arise from subrogation (whether such subrogation is 

contractual, equitable or statutory), assignment (whether such assignment is contractual, equitable or statutory), or otherwise in connection with payments 

made or to be made by the applicable insurer to insured tort victims, and whether arising as a matter of state or federal law, including, without limitation, Section 

509 of the Bankruptcy Code. The undersigned holder of these claims reserves its rights to assert any and all claims arising from, as a result of, or in connection 

with payments made or to be made by the undersigned insurer (or, where the claimant is the direct or indirect assignee of claims of an insurer, the applicable 

insurer (the “assignor insurer”)) to or on behalf of each tort victim insured by the undersigned insurer or by the assignor insurer, and to assert all such claims 

both cumulatively and in the alternative.

Case: 19-30088 Doc# 2043-1 Filed: 05/16/19 Entered: 05/16/19 12:40:58 Page 1

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Name of creditor 5 Name of creditor 6

Name of creditor 7 Name of creditor 8

Name of creditor 9 Name of creditor 10

3. If more than one creditor is 

listed in item 2 above, are the 

creditors part of one carrier 

group? 

No.

Yes. Identify the group: _________________________________________________________________________

4. Has this subrogation claim 

been acquired from someone 

else (other than an insured)?

No

Yes. From whom? _____________________________________________________________________________

5. Nature of Claim and Basis 

for Claim. 

See Attachment 1

6. Where should notices and 

payments to the creditor be 

sent? If additional space 

needed, please attach a 

schedule. 

Federal Rule of Bankruptcy 

Procedure (FRBP) 2002(g)

Where should notices to the creditor/creditor group 

be sent?

Where should payments to the creditor/creditor 

group be sent? (if different)

Name Name

Number Street Number Street

City State Zip Code City State Zip Code

Contact phone ___________________________ Contact phone ___________________________

Contact email ____________________________ Contact email ____________________________

7. Was a lawsuit filed 

prepetition in connection with 

these subrogation claim(s)? 

Please identify any lawsuits filed 

pre-petition for any subrogation 

claim(s) or group(s) of 

subrogation claims. Do not 

include lawsuits for related 

individual tort claims.

No

Yes. Please identify the lawsuit(s):

Docket Number: _______________________________________________________________

Court: _______________________________________________________________________

8. Does this claim amend one 

already filed?

No

Yes. Claim number assigned (if known) _______________ Filed on __________________________

 MM / DD / YYYY

9. Do you know if anyone else 

(other than the underlying 

insureds) has filed a proof of 

claim for this subrogation 

claim?

No

Yes. Who made the earlier filing? _______________

Case: 19-30088 Doc# 2043-1 Filed: 05/16/19 Entered: 05/16/19 12:40:58 Page 2

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Part 2: Give Information About the Claims 

10. Liquidated Claims. What is the aggregate amount of liquidated claims (i.e., payments made to insureds as of the date hereof)? 

$ _________________________

11. Total number of liquidated insured losses that form the basis of this claim: ________________________

12. Contingent or Unliquidated Claims. What is the aggregate amount of estimated contingent and unliquidated claims (i.e., amounts reserved or 

estimated for claims to be paid to insureds for incidents that occurred prepetition)?

$ _________________________

13. Total Claim. What is the aggregate amount of liquidated, estimated, contingent and/or unliquidated claims (i.e., the sum of the answers to part 2 

questions 1 and 3)? 

$__________________________

14. Attorneys’ Fees and Costs. This claim includes additional amounts for attorneys’ fees and costs in amounts not yet determined. 

15. Provide supporting data 

for each of the underlying 

insured losses paid to date.

Within five (5) business days after receipt of an Omnibus Insurance Subrogation Proof of Claim in which a claimant 

asserts a claim (or claims) on account of multiple insured losses, Prime Clerk will send the filer an email request to 

provide an electronic excel file containing the following information for each of the individual insured losses that form the 

basis of this omnibus proof of claim. This information, to the extent maintained by the claimant in the ordinary course of 

business, shall be provided to Prime Clerk substantially in the form requested so as to be received within 10 business 

days of the email request being sent by Prime Clerk or as soon as reasonably practicable thereafter. When submitting 

the electronic files, please provide definitions or explanations of all defined terms used therein. The information 

submitted to Prime Clerk may be updated and/or revised from time to time by the claim filer. The information sent to 

Prime Clerk shall be kept confidential by Prime Clerk, the Debtors and their professionals and shall not (a) be filed with 

the Court unless under seal or (b) otherwise made available to the public or any third party, without the express consent 

of the undersigned creditor.

1. Insurance Company Name

2. Fire Name

3. Insurance Policy Number

4. Insurance Claim Number

5. Claim Type (e.g., Auto, Commercial, Homeowners)

6. Claim Status (open/closed)

7. Type of Loss (e.g., structure, personal property, automobile)

8. Insured Name

9. Loss Location Street Address

10. Loss Location City

11. Loss Location ZIP

12. Date of Loss

13. Total Paid to date by Loss Type (e.g. structure, personal property, automobile)

Case: 19-30088 Doc# 2043-1 Filed: 05/16/19 Entered: 05/16/19 12:40:58 Page 3

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Part 3: Sign Below

The person completing this 

proof of claim must sign and 

date it.

FRBP 90011(b).

If you file this claim 

electronically, FRBP 

5005(a)(2) authorizes courts to 

establish local rules specifying 

what a signature is.

A person who files a 

fraudulent claim could be 

filed up to $500,000, 

imprisoned for up to 5 years 

or both.

18 U.S.C. §§ 152, 157 and 

3571.

Check the appropriate box:

I am the creditor.

I am the creditor’s attorney or authorized agent.

I understand that an authorized signature on this Omnibus Proof of Claim serves as an acknowledgement that when 

calculating the amount of the claim, the creditor gave the debtor credit for any payments received toward the debt.

I have examined the information in this Omnibus Proof of Claim and have a reasonable belief that the information is 

true and correct.

I declare under penalty of perjury that the foregoing is true and correct.

Executed on date __________________________

 MM / DD / YYYY

_____________________________________________________________

Signature

Print the name of the person who is completing and signing this claim:

Name

Title

First name Middle name Last Name

Company

Address

Identify the corporate servicer as the company if the authorized agent is a servicer.

Number Street

City State Zip Code

Contact phone ______________________________________ Email _______________________________________________

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