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Exhibit 1 

Revised Wildfire Subrogation Claimant Proof of Claim Form 

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20/19 15:11:18 Page 1

of 18
Part 1:

UNITED STATES BANKRUPTCY COURT 

NORTHERN DISTRICT OF CALIFORNIA (SAN FRANCISCO DIVISION)

In re: 

PG&E CORPORATION, 

- and - 

PACIFIC GAS AND ELECTRIC 

COMPANY, 

 Debtors.

Bankruptcy Case 

No. 19-30088 (DM) 

Chapter 11 

(Lead Case) 

(Jointly Administered)

Proof of Claim (Wildfire Related – Subrogation Insurers) 

Read the instructions before filling out this form. 

This form is for Subrogation Insurers to assert general unsecured claims based on amounts paid or reserved for damages or 

losses resulting from a wildfire. Do not use this form to assert any other pre-petition claims. 

Include the aggregate total estimated amount of all insurance subrogation claims, across all individual policies, held by a single 

creditor on this Proof of Claim. 

Complete Attachment 1, substantially in the form provided, to provide detailed information about each of the individual claims that 

are included in the aggregate total amounts shown on this Proof of Claim, to the extent the information is maintained in the 

ordinary course of business. When submitting Attachment 1, please provide definitions or explanations of all defined terms used 

therein. Attachment 1 must be provided to Prime Clerk no later than 30 days after the Bar Date. 

Signing this form constitutes an acknowledgement that you will provide additional support documentation for each individual claim on a 

confidential and professionals’ eyes only basis to counsel for the Debtors, the U.S. Trustee, any Statutory Committee appointed in these 

cases, and any additional parties the Court directs but only after each such party agrees to keep the information provided confidential, 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. 

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

any documents that support the claim. Do not send original documents; they may be destroyed after scanning. If the documents are not 

available, explain in an attachment. 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. Fill in all the information about the claim as of January 29, 2019, except where otherwise 

specified. 

Identify the Claim 

1. Is this proof of claim being filed 

on behalf of one or multiple 

creditors (i.e., other affiliated 

insurance companies)?

 One creditor

 More than one creditor

2. Who is (are) the current

creditor(s)? For more than ten 

creditors, please attach 

separate schedule.

 Name of Creditor 1 

Name of Creditor 2

 Name of Creditor 3 

Name of Creditor 4

 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. Are the creditor(s) part of one 

Carrier Group? (See definition of 

Carrier Group in the attached 

instructions) 

 No

 Yes. Identify the group: ________ ________

4. Has this subrogation claim been

acquired from someone else 

other than the underlying 

insured? (See question 10) 

 No 

 Yes. From whom? 

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20/19 15:11:18 Page 2

of 18
Part 3:

Part 2:

5. Where should notices and 

payments to the

Where should notices to the creditor(s) be sent? Where should payments to the creditor(s) 

be sent? (if different)

Creditor(s) be sent?

Federal Rule of Bankruptcy 

Procedure (FRBP) 2002(g) Name 

Number Street 

City State ZIP Code 

Contact phone 

Contact email 

Name 

Number Street 

City State ZIP Code 

Contact phone 

Contact email 

6. Does this claim amend one already 

filed?

 No 

 Yes. Claim number on court claims registry (if known) Filed on 

MM / DD / YYYY 

7. Was a subrogation lawsuit filed prepetition in connection with this 

(these) claim(s)?

 No 

 Yes. Please Identify Lawsuit: Case/Docket # Court: 

Attorney Information (Optional) 

8. Who represents you 

in this matter?

Who represents you in this matter?

You do not need an 

attorney to file this 

form 

 

Law Firm Name 

 

Attorney Name 

 

Number Street 

City State ZIP Code 

Contact phone Contact email 

 Give Information About the Claim as of the Date the Case Was Filed 

9. Provide a summary of 

the underlying claims:

Subrogation insurers 

must produce a file 

containing details of 

the individual claims 

(paid or reserved) that 

form the basis of this 

claim. 

Name of Insurer (if different than the 

creditor listed in question 1): 

Nature of underlying claim(s) (check all that apply):

 Structure and Real Property Claims 

 Debris Removal Claims 

 Personal Property Claims 

 Additional Living Expenses, Business Interruption, Loss of Use/Rent Claims 

 Automobile (Rental, Loss of Use, Tow, Storage) Claims

 Other. Describe: 

Total number of insured losses that form the basis of this claim: 

Total aggregate amount of liquidated claims (i.e., payments made 

 to insureds) as of the date hereof: $ 

Total aggregate amount of reserved claims as of the date hereof: $ 

Total aggregate amount of estimated claims (i.e., claims that have 

not been paid or reserved but are estimated for relevant wildfire 

incidents that occurred pre-petition): $ 

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20/19 15:11:18 Page 3

of 18
10. Provide supporting 

documentation for 

any underlying claims 

that have been 

assigned, sold or 

otherwise transferred 

to the Creditor.

If any of the individual claims that form the basis of this claim have been assigned, sold or otherwise transferred to the 

Creditor, please provide the following additional information for each individual claim, or such additional information as 

otherwise agreed to between the Creditor and the Debtors: 

1. A copy of the original contract of sale / assignment of contract for the underlying subrogated claim, or any other 

documentation reflecting a valid assignment of the subrogated rights. 

2. A copy of insurer’s written notification to insured (pursuant to 10 Cal. Code Regs. § 2695.7(p)) of its election not to directly 

pursue subrogation or discontinuation of its pursuit of subrogation. 

3. A copy of the underlying policy for the subrogated claim. 

Due to the voluminous nature of this information and confidentiality concerns, in lieu of attaching this information to their Proof 

of Claim, Creditors holding assigned claims may agree to provide this information directly to the Debtors on terms acceptable 

to such Creditors and the Debtors including pursuant to a Non-Disclosure Agreement. 

 

Part 4: Sign Below    

The person completing

this proof of claim must

sign and date it.

FRBP 9011(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

fined 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 am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004. 

 I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005. 

I understand that an authorized signature on this Proof of Claim serves as an acknowledgment 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 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 

First name Middle name Last name 

Title 

Company 

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

Address 

Number Street 

City State ZIP Code 

Contact phone Email 

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20/19 15:11:18 Page 4

of 18
Proof of Claim (Wildfire Related – Subrogation Insurers) Page 1

Instructions for Proof of Claim (Wildfire Related – Subrogation 

Insurers) 

United States Bankruptcy Court 

These instructions and definitions generally explain the law. In certain circumstances, such as bankruptcy cases that debtors do 

not file voluntarily, exceptions to these general rules may apply. You should consider obtaining the advice of an attorney, 

especially if you are unfamiliar with the bankruptcy process and privacy regulations.

How to fill out this form

 Fill in all of the information about the claim as of 

January 29, 2019.

 Attach any supporting documents to this form.

Attach redacted copies of any documents that show that the

debt exists, a lien secures the debt, or both. (See the

definition of redaction on the next page.) 

 Do not attach original documents because 

attachments may be destroyed after scanning.

 If the claim is based on delivering health care goods 

or services, do not disclose confidential health care 

information. Leave out or redact confidential 

information both in the claim and in the attached 

documents.

 A Proof of Claim form and any attached documents 

must show only the last 4 digits of any social security 

number, individual’s tax identification number, or 

financial account number, and only the year of any 

person’s date of birth. See Bankruptcy Rule 9037. 

 For a minor child, fill in only the child’s initials and 

the full name and address of the child’s parent or 

guardian. For example, write A.B., a minor child (John

Doe, parent, 123 Main St., City, State). See Bankruptcy

Rule 9037. 

Confirmation that the claim has been filed

To receive confirmation that the claim has been filed, either 

enclose a stamped self-addressed envelope and a copy of this 

form. You may view a list of filed claims in this case by 

visiting the Claims and Noticing Agent's website at

https://restructuring.primeclerk.com/pge. 

Understand the terms used in this form

Carrier Group: As used herein, “carrier group” refers to 

affiliated insurers listed in response to question 2 using a 

common, public-facing name. The use of the term “carrier 

group” does not imply any formal affiliation requirement. 

Answering this question is without prejudice to the assertion 

of claims by any member of the carrier group to the extent its 

claims are not included in this proof of claim. 

Claim: A creditor’s right to receive payment for a debt that the 

debtor owed on the date the debtor filed for bankruptcy. 11 

U.S.C. §101 (5). A claim may be secured or unsecured. 

Creditor: A person, corporation, or other entity to whom a

debtor owes a debt that was incurred on or before the date the

debtor filed for bankruptcy. 11 U.S.C. § 101 (10). 

Debtor: A person, corporation, or other entity who is in

bankruptcy. Use the debtor’s name and case number as shown in 

the bankruptcy notice you received. 11 U.S.C. § 101 (13). 

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. 

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20/19 15:11:18 Page 5

of 18
Proof of Claim (Wildfire Related – Subrogation Insurers) Page 2

Information that is entitled to privacy: A Proof of Claim form 

and any attached documents must show only the last 4 digits of 

any social security number, an individual’s tax identification 

number, or a financial account number, only the initials of a 

minor’s name, and only the year of any person’s date of birth. If 

a claim is based on delivering health care goods or services, 

limit the disclosure of the goods or services to avoid 

embarrassment or disclosure of confidential health care 

information. You may later be required to give more

information if the trustee or someone else in interest objects to

the claim. 

Proof of claim: A form that shows the amount of debt the

debtor owed to a creditor on the date of the bankruptcy filing.

The form must be filed in the district where the case is pending. 

Redaction of information: Masking, editing out, or deleting

certain information to protect privacy. Filers must redact or

leave out information entitled to privacy on the Proof of Claim 

form and any attached documents. 

Secured claim under 11 U.S.C. § 506(a): A claim backed by

a lien on particular property of the debtor. A claim is secured

to the extent that a creditor has the right to be paid from the

property before other creditors are paid. The amount of a

secured claim usually cannot be more than the value of the

particular property on which the creditor has a lien. Any

amount owed to a creditor that is more than the value of the

property normally may be an unsecured claim. But exceptions

exist; for example, see 11 U.S.C. § 1322(b) and the final

sentence of § 1325(a). 

Examples of liens on property include a mortgage on real

estate or a security interest in a car. A lien may be voluntarily

granted by a debtor or may be obtained through a court

proceeding. In some states, a court judgment may be a lien. 

Unsecured claim: A claim that does not meet the

requirements of a secured claim. A claim may be unsecured in

part to the extent that the amount of the claim is more than the

value of the property on which a creditor has a lien. 

Offers to purchase a claim

Certain entities purchase claims for an amount that is less than

the face value of the claims. These entities may contact

creditors offering to purchase their claims. Some written

communications from these entities may easily be confused

with official court documentation or communications from the

debtor. These entities do not represent the bankruptcy court, the 

bankruptcy trustee, or the debtor. A creditor has no obligation 

to sell its claim. However, if a creditor decides to sell its claim, 

any transfer of that claim is subject to Bankruptcy Rule 

3001(e), any provisions of the Bankruptcy Code (11 U.S.C. § 

101 et seq.) that apply, and any orders of the bankruptcy court 

that apply. 

Please send completed Proof(s) of Claim to:

If by first class mail: 

PG&E Corporation Claims Processing Center 

c/o Prime Clerk LLC 

Grand Central Station, PO Box 4850 

New York, NY 10163-4850 

If by overnight courier or hand delivery: 

PG&E Corporation Claims Processing Center 

c/o Prime Clerk LLC 

850 Third Avenue, Suite 412 

Brooklyn, NY 11232 

Do not file these instructions with your form

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20/19 15:11:18 Page 6

of 18
Attachment 1 to Omnibus Insurance Subrogation P

Insurance 

Underwriting 

Company

Carrier Group Acquiror (if any) 

Insur

Creditor 

Claim Type 

(Auto, Commercial, 

Homeowners)

Insurance Policy 

No. 

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/2

of 18
Attachment 1 to Omnibus Insurance Subrogation P

First Name Street City State Zip Code 

Loss Location (If Not Insured Address) 

Date of Loss 

d Name

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/2

of 18
Attachment 1 to Omnibus Insurance Subrogation P

Homeowners

Building / Appurtenant 

Structure / Debris 

Removal

Contents / Business Personal 

Property / Debris Removal (if not 

included in prior column)

Added Living Expense / 

Business Interruption, 

Loss of Use/Rent

Auto / Re

Use / To

aim Type)

Loss Amount Breakdown (by Loss Type)

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/2

of 18
Attachment 1 to Omnibus Insurance Subrogation P

Corresponding 

Household Group 

No. 

Corresponding 

Individual Plaintiff 

Claim, if known 

(yes/no)

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20

of 18
Part 1:

UNITED STATES BANKRUPTCY COURT 

NORTHERN DISTRICT OF CALIFORNIA (SAN FRANCISCO DIVISION)

In re: 

PG&E CORPORATION, 

- and - 

PACIFIC GAS AND ELECTRIC 

COMPANY, 

 Debtors.

Bankruptcy Case 

No. 19-30088 (DM) 

Chapter 11 

(Lead Case) 

(Jointly Administered) 

Proof of Claim (Wildfire Related – Subrogation Insurers) 

Read the instructions before filling out this form. 

This form is for Subrogation Insurers to assert general unsecured claims based on amounts paid or reserved for damages or 

losses resulting from a wildfire. Do not use this form to assert any other pre-petition claims. 

Include the aggregate total estimated amount of all insurance subrogation claims, across all individual policies, held by a single 

creditor on this Proof of Claim. 

Complete Attachment 1, substantially in the form provided, to provide detailed information about each of the individual claims that 

are included in the aggregate total amounts shown on this Proof of Claim, to the extent the information is maintained in the 

ordinary course of business. When submitting Attachment 1, please provide definitions or explanations of all defined terms used

therein. Attachment 1 must be provided to Prime Clerk no later than 30 days after the Bar Date. 

Signing this form constitutes an acknowledgement that you will provide additional support documentation for each individual claim on a 

confidential and professionals’ eyes only basis to counsel for the Debtors, the U.S. Trustee, any Statutory Committee appointed in these 

cases, and any additional parties the Court directs but only after each such party agrees to keep the information provided confidential, 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. 

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

any documents that support the claim. Do not send original documents; they may be destroyed after scanning. If the documents are not 

available, explain in an attachment. 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. Fill in all the information about the claim as of January 29, 2019, except where otherwise 

specified. 

Identify the Claim 

1. Is this proof of claim being filed 

on behalf of one or multiple 

creditors (i.e., other affiliated 

insurance companies)?

 One creditor

 More than one creditor

2. Who is (are) the current

creditor(s)? For more than ten 

creditors, please attach 

separate schedule.

 

Name of Creditor 1

 

Name of Creditor 2

 

Name of Creditor 3

 

Name of Creditor 4

 

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. Are the creditor(s) part of one 

carrier group?Carrier Group? 

(See definition of Carrier Group in 

the attached instructions)

 No

 Yes. Identify the group: 

4. Has this subrogation claim been

acquired from someone else? 

 other than the underlying 

insured? (See question 910) 

 No 

 Yes. From whom? 

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20/19 15:11:18 Page 11

of 18
Proof of Claim (Wildfire Related – Subrogation Insurers) Page 2

5. Where should notices and 

payments to the

Where should notices to the creditor(s) be sent? Where should payments to the creditor(s) 

be sent? (if different) 

Creditor(s) be sent?

Federal Rule of Bankruptcy 

Procedure (FRBP) 2002(g) Name 

Number Street 

City State ZIP Code 

Contact phone 

Contact email 

Name 

Number Street 

City State ZIP Code 

Contact phone 

Contact email 

6. Does this claim amend one already 

filed?

 No 

 Yes. Claim number on court claims registry (if known) Filed on 

MM / DD / YYYY 

7. Do you know if anyone else has filed 

a proof of claim for this claim?

 No 

 Yes. Who made the earlier filing? 

87. Was a subrogation lawsuit filed prepetition in connection with this 

(these) claim(s)?

 No 

 Yes. Please Identify Lawsuit: Case/Docket # Court: 

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20/19 15:11:18 Page 12

of 18
Proof of Claim (Wildfire Related – Subrogation Insurers) Page 3

Part 3:

Part 2: Attorney Information (Optional) 

98. Who represents you 

in this matter?

Who represents you in this matter?

You do not need an 

attorney to file this 

form 

 

Law Firm Name 

 

Attorney Name 

 

Number Street 

City State ZIP Code 

Contact phone Contact email 

 Give Information About the Claim as of the Date the Case Was Filed 

109. Provide a 

summary of the 

underlying claims:

Subrogation insurers 

must produce a file 

containing details of 

the individual claims 

(paid or reserved) that 

form the basis of this 

claim. (See question 

8)

Name of Insurer (if different than the 

creditor listed in question 1): 

Nature of underlying claim(s) (check all that apply):

 Structure and Real Property Claims 

 Debris Removal Claims 

 Personal Property Claims 

 Additional Living Expenses, Business Interruption, Loss of Use/Rent Claims 

 Automobile (Rental, Loss of Use, Tow, Storage) Claims

 Other. Describe: 

Total number of individual claims insured losses that form the basis of this claim: 

Total aggregate claim amount (amount of liquidated claims (i.e., payments made 

to reflect all individual insureds) as of the date hereof: $ 

 

Total aggregate amount of reserved claims as of the date hereof: $ 

Total aggregate amount of estimated claims (i.e., claims that have 

not been paid or reserved by the insurer):but are estimated for relevant wildfire 

incidents that occurred pre-petition): $ 

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20/19 15:11:18 Page 13

of 18
Proof of Claim (Wildfire Related – Subrogation Insurers) Page 4

11. Provide supporting 

data for each of the 

underlying claims.

Within five (5) business days after receipt of a Wildfire Subrogation Claimant Proof of Claim Form in which a claimant 

asserts multiple Wildfire Subrogation Claims, Prime Clerk will send the filer an email request to provide an electronic file 

containing the following information for each of the individual claims that form the basis of this claim. This information 

must be provided to Prime Clerk in the form requested so as to be received within 10 business days of the email request 

being sent by Prime Clerk. When submitting the electronic files, please provide definitions or explanations of all defined 

terms used therein. 

1. Insurance Company Name 

2. Fire Name 

3. Policy Number 

4. Policy Limit 

5. Claim Number 

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

7. Claim Status (Open/Closed) 

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

9. Insured Name 

10. Parcel ID 

11. Loss Location Street Address 

12. Loss Location City 

13. Loss Location ZIP 

14. Date of Loss 

15. Total Paid/Reserved by Claim Type (e.g., Auto, Commercial, Homeowners) 

16. Total Paid/Reserved by Loss Type (e.g., structure, personal property, automobile): 

12. Provide supporting 

documentation for 

any underlying claims 

that have been 

assigned, sold or 

otherwise transferred 

to the Creditor.

If any of the individual claims that form the basis of this claim have been acquired through an assignment, please provide the 

following additional information for each individual claim: 

1. A copy of the original contract of sale / assignment of contract for the underlying subrogated claim, and/or any other 

documentation reflecting a valid assignment of the subrogated rights. 

2. A copy of insurer’s written notification to insured (pursuant to 10 Cal. Code Regs. § 2695.7(p)) of its election not to directly 

pursue subrogation or discontinuation of its pursuit of subrogation. 

3. A copy of the underlying policy for the subrogated claim. 

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20/19 15:11:18 Page 14

of 18
Proof of Claim (Wildfire Related – Subrogation Insurers) Page 5

10. Provide supporting 

documentation for 

any underlying claims 

that have been 

assigned, sold or 

otherwise transferred 

to the Creditor.

If any of the individual claims that form the basis of this claim have been assigned, sold or otherwise transferred to the 

Creditor, please provide the following additional information for each individual claim, or such additional information as 

otherwise agreed to between the Creditor and the Debtors: 

1. A copy of the original contract of sale / assignment of contract for the underlying subrogated claim, or any other 

documentation reflecting a valid assignment of the subrogated rights. 

2. A copy of insurer’s written notification to insured (pursuant to 10 Cal. Code Regs. § 2695.7(p)) of its election not to directly 

pursue subrogation or discontinuation of its pursuit of subrogation. 

3. A copy of the underlying policy for the subrogated claim. 

Due to the voluminous nature of this information and confidentiality concerns, in lieu of attaching this information to their Proof 

of Claim, Creditors holding assigned claims may agree to provide this information directly to the Debtors on terms acceptable 

to such Creditors and the Debtors including pursuant to a Non-Disclosure Agreement. 

 

Part 4: Sign Below    

The person completing

this proof of claim must

sign and date it.

FRBP 9011(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

fined 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 am the trustee, or the debtor, or their authorized agent. Bankruptcy Rule 3004. 

 I am a guarantor, surety, endorser, or other codebtor. Bankruptcy Rule 3005. 

I understand that an authorized signature on this Proof of Claim serves as an acknowledgment 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 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 

First name Middle name Last name 

Title 

Company 

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

Address 

Number Street 

City State ZIP Code 

Case: 19-30088 Doc# 2688-1 Filed: 06/20/19 Entered: 06/20/19 15:11:18 Page 15

of 18
Proof of Claim (Wildfire Related – Subrogation Insurers) Page 1

Instructions for Proof of Claim (Wildfire Related – Subrogation 

Insurers) 

United States Bankruptcy Court 

These instructions and definitions generally explain the law. In certain circumstances, such as bankruptcy cases that debtors do 

not file voluntarily, exceptions to these general rules may apply. You should consider obtaining the advice of an attorney, 

especially if you are unfamiliar with the bankruptcy process and privacy regulations.

How to fill out this form

 Fill in all of the information about the claim as of 

January 29, 2019.

 If the claim has been acquired from someone else, 

then state the identity of the last party who owned the

claim or was the holder of the claim and who transferred it 

to you before the initial claim was filed. 

 Attach any supporting documents to this form.

Attach redacted copies of any documents that show that the

debt exists, a lien secures the debt, or both. (See the

definition of redaction on the next page.) 

 Do not attach original documents because 

attachments may be destroyed after scanning.

 If the claim is based on delivering health care goods 

or services, do not disclose confidential health care 

information. Leave out or redact confidential 

information both in the claim and in the attached 

documents.

 A Proof of Claim form and any attached documents 

must show only the last 4 digits of any social security 

number, individual’s tax identification number, or 

financial account number, and only the year of any 

person’s date of birth. See Bankruptcy Rule 9037. 

 For a minor child, fill in only the child’s initials and 

the full name and address of the child’s parent or 

guardian. For example, write A.B., a minor child (John

Doe, parent, 123 Main St., City, State). See Bankruptcy

Rule 9037. 

Confirmation that the claim has been filed

To receive confirmation that the claim has been filed, either 

enclose a stamped self-addressed envelope and a copy of this 

form. You may view a list of filed claims in this case by 

visiting the Claims and Noticing Agent's website at

https://restructuring.primeclerk.com/pge. 

Understand the terms used in this form

Carrier Group: As used herein, “carrier group” refers to 

affiliated insurers listed in response to question 2 using a 

common, public-facing name. The use of the term “carrier 

group” does not imply any formal affiliation requirement. 

Answering this question is without prejudice to the assertion 

of claims by any member of the carrier group to the extent its 

claims are not included in this proof of claim. 

Claim: A creditor’s right to receive payment for a debt that the 

debtor owed on the date the debtor filed for bankruptcy. 11 

U.S.C. §101 (5). A claim may be secured or unsecured. 

Creditor: A person, corporation, or other entity to whom a

debtor owes a debt that was incurred on or before the date the

debtor filed for bankruptcy. 11 U.S.C. § 101 (10). 

Debtor: A person, corporation, or other entity who is in

bankruptcy. Use the debtor’s name and case number as shown in 

the bankruptcy notice you received. 11 U.S.C. § 101 (13). 

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. 

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Proof of Claim (Wildfire Related – Subrogation Insurers) Page 2

Information that is entitled to privacy: A Proof of Claim form 

and any attached documents must show only the last 4 digits of 

any social security number, an individual’s tax identification 

number, or a financial account number, only the initials of a 

minor’s name, and only the year of any person’s date of birth. If 

a claim is based on delivering health care goods or services, 

limit the disclosure of the goods or services to avoid 

embarrassment or disclosure of confidential health care 

information. You may later be required to give more

information if the trustee or someone else in interest objects to

the claim. 

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Proof of claim: A form that shows the amount of debt the

debtor owed to a creditor on the date of the bankruptcy filing.

The form must be filed in the district where the case is pending. 

Redaction of information: Masking, editing out, or deleting

certain information to protect privacy. Filers must redact or

leave out information entitled to privacy on the Proof of Claim 

form and any attached documents. 

Secured claim under 11 U.S.C. § 506(a): A claim backed by

a lien on particular property of the debtor. A claim is secured

to the extent that a creditor has the right to be paid from the

property before other creditors are paid. The amount of a

secured claim usually cannot be more than the value of the

particular property on which the creditor has a lien. Any

amount owed to a creditor that is more than the value of the

property normally may be an unsecured claim. But exceptions

exist; for example, see 11 U.S.C. § 1322(b) and the final

sentence of § 1325(a). 

Examples of liens on property include a mortgage on real

estate or a security interest in a car. A lien may be voluntarily

granted by a debtor or may be obtained through a court

proceeding. In some states, a court judgment may be a lien. 

Unsecured claim: A claim that does not meet the

requirements of a secured claim. A claim may be unsecured in

part to the extent that the amount of the claim is more than the

value of the property on which a creditor has a lien. 

Offers to purchase a claim

Certain entities purchase claims for an amount that is less than

the face value of the claims. These entities may contact

creditors offering to purchase their claims. Some written

communications from these entities may easily be confused

with official court documentation or communications from the

debtor. These entities do not represent the bankruptcy court, the 

bankruptcy trustee, or the debtor. A creditor has no obligation 

to sell its claim. However, if a creditor decides to sell its claim, 

any transfer of that claim is subject to Bankruptcy Rule 

3001(e), any provisions of the Bankruptcy Code (11 U.S.C. § 

101 et seq.) that apply, and any orders of the bankruptcy court 

that apply. 

Please send completed Proof(s) of Claim to:

If by first class mail: 

PG&E Corporation Claims Processing Center 

c/o Prime Clerk LLC 

Grand Central Station, PO Box 4850 

New York, NY 10163-4850 

If by overnight courier or hand delivery: 

PG&E Corporation Claims Processing Center 

c/o Prime Clerk LLC 

850 Third Avenue, Suite 412 

Brooklyn, NY 11232 

Do not file these instructions with your form

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