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Weil, Gotshal & Manges LLP 

767 Fifth Avenue 

New York, NY 10153-0119

Exhibit C-3

Wildfire Subrogation Claimant Proof of Claim Form

Case: 19-30088 Doc# 1784-7 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 1

of 6
Proof of Claim (Wildfire Related – Subrogation Insurers) Page 1

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. 

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?

 No

 Yes. Identify the group: 

4. Has this claim been acquired 

from someone else? 

(See question 9) 

 No 

 Yes. From whom? 

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? 

8. Was a lawsuit filed pre-petition in 

connection with this (these) 

claim(s)?

 No 

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

Case: 19-30088 Doc# 1784-7 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 2

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

Part 3:

Part 2: Attorney Information (Optional) 

9. 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 

10. 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 Claims 

 Personal Property Claims 

 Automobile Claims

 Other. Describe: 

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

Total aggregate claim amount (amount to reflect all individual 

claims that have been paid or reserved by the insurer): $ 

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# 1784-7 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 3

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

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# 1784-7 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 4

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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

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). 

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. 

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# 1784-7 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 5

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

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# 1784-7 Filed: 05/01/19 Entered: 05/01/19 15:32:50 Page 6

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