|
CLAIM FORM FOR BOILER/MACHINERY DAMAGE/LOSS
UNIVERSITY OF MARYLAND, BALTIMORE
Date of Incident : _ _ / _ _ / _ _ Time : _ _: _ _ A.M. / P.M.
Location of Incident : Building (name) : _________________________________
Street : _________________________________
City State Zip : _________________________________
Contact Person : _________________________________
Detailed Explanation Of Incident:
Cause: __ Fire __ Flood __ Explosion __ Equipment Failure (specify:_____________)
__ Storm / Wind/ Lightening __ Vandalism __ Other
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Make/Model of Equipment:_______________________________________________________
Estimated Property (Building) Loss / Damage : $______________ **
UMB Police Report #_________ Fire Dept
Report #___________
Name of person completing form: ___________________________
Phone:_______ Fax:______
Completed form must be faxed to Risk
Management at 706-1520 within 24 hours.
No repairs are to be performed unless
approved by the commercial carrier and/or Risk Management. |
