American Contractors Indemnity Co – Fill Out and Use This PDF

Provide your name or names, the company name if a company is the claimant, mailing address, telephone numbers, fax number and email address.

Provide the contractor's license number, names, mailing address, telephone numbers, fax number, email address and website address.

Mark Yes or No: does your claim relate to an agreement between you and the contractor for work upon your residence? Provide the physical address of the location or locations of the projects. Provide legible copies of the agreements and any related documentation such as bids, estimates, proposals, change orders and building permits.

If the agreement was oral or if there were oral modifications please provide the details. Examples include: the date the agreement was entered into, the scope of work, the start and completion date of performance, the amount to be paid and the timing of payments under the agreement.

If not already included in the documentation requested in 4, provide the original amount of the agreement, the amount of any changes, and the amount paid to date.

Provide your estimate of the percentage of work completed by the contractor to date: Labor + Materials = Total.

If you assert you were damaged by the contractor abandoning your construction project without legal excuse, provide the dates of abandonment, copies of correspondence or other documentation, a description of the history and circumstances, and the amount of damages you assert.

Provide the following if you assert you were damaged by the contractor diverting contract funds paid to it for use on your construction project and/or failing to account for the use and application of payments received: the dates of the payments, copies of the payments, copies of preliminary notices, mechanic's liens and related correspondence from the contractor's subcontractors and suppliers, a description of the history and circumstances, and the amount of damages you assert.

If you assert you were damaged by the contractor failing to follow accepted trade standards for good and workmanlike construction, provide a description of what work you believe was performed poorly, written evaluations of the contractor's work from other licensed contractors, and written estimates to repair or replace the contractor's work. If you believe pictures or diagrams would assist in understanding the poor work, you can submit those pictures along with this claim form.

If you elect to proceed to have the work completed before an inspection may be performed, take pictures of the first contractor's work that you elect to repair or replace, if possible. Also provide the contact information of the subsequent licensed contractor you utilize to perform the work and copies of the related documentation.

Provide the following if you assert you were damaged by the contractor materially breaching the contract: the dates of the material breach, copies of correspondence or other documentation, a description of the history and circumstances, and the amount of damages you assert.

Should you assert you were damaged by the contractor failing to progress with construction with reasonable diligence, provide the dates the work stopped progressing with reasonable diligence, copies of correspondence or other documentation, and a description of the history and circumstances.

If you have filed a complaint with the Contractor's State License Board, provide copies of your complaint form and any correspondence between you and the CSLB to date and subsequent to your submission of this claim form.

If you are or become involved in litigation, arbitration or other legal proceeding with the contractor regarding this claim, inform of same and provide copies of the paperwork relating to that legal proceeding.

You are not required to obtain a judgment against the principal prior to asserting a claim on the bond, but legal proceedings between the claimant and the contractor are relevant to the investigation of your claim.

The answers to this Proof of Claim form are the basis for a claim for payment of money under the California Business and Professions Code, Division 3, Chapter 9, beginning with Section 7000, and the undersigned certifies and declares under penalty of perjury that the foregoing is true and correct.

Fill in Dated with the Month - Day and the Year, and Place of Execution with the City.

The complainant signs on Signature of Complainant.

California Insurance Code Section 1871.2: any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in State Prison.