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CLAIM FORM Mail to PG E San Bruno Claims Department 1850 Gateway Blvd. 7th floor Concord CA 94520 E-mail SanBrunoClaims pge. com Fax 415-973-2017 PLEASE PRINT Mr. / Mrs. / Ms. / Dr. Last Name First Name Spouse s Name Business name if claim is for business Work Telephone Home Telephone PG E Account Number Mailing Address - Street Apt. Number City State Zip Code Email Address PROPERTY DAMAGE Attach repair estimates invoices proof of purchase or supporting documents Model Name Number Item Description Make/Brand Age Cost to Repair Amount Claimed Size Total Amount Claimed Were you injured Yes No If yes please describe Other Losses lost wages lost revenue medical expenses etc* Use Additional paper if necessary. com Fax 415-973-2017 PLEASE PRINT Mr. / Mrs. / Ms. / Dr. Last Name First Name Spouse s Name Business name if claim is for business Work Telephone Home Telephone PG E Account Number Mailing Address - Street Apt. Number City State Zip Code Email Address PROPERTY DAMAGE Attach repair estimates invoices proof of purchase or supporting documents Model Name Number Item Description Make/Brand Age Cost to Repair Amount Claimed Size Total Amount Claimed Were you injured Yes No If yes please describe Other Losses lost wages lost revenue medical expenses etc* Use Additional paper if necessary. .

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