|
CLAIM FORM FOR TORT (LIABILITY) LOSS
UNIVERSITY OF MARYLAND, BALTIMORE
Date of Incident : _ _ / _ _ / _ _ Time : _ _: _ _ A.M. / P.M.
Claimant Name ___________________________________________
Address __________________________________________________
Phone Number __________________________________________
Location of Incident : Building (name) : _________________________________
Floor / Room / Lab # ______________________________
Street : _________________________________
City State Zip : _________________________________
Contact Person : _________________________________
Detailed Explanation Of Incident:
Type of Loss: _____ Bodily Injury ____ Property Damage
Detailed Explanation of Incident
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Estimated Value of Claim : $______________ **
UMB Police Report #_________
Name of person completing form: ___________________________ Phone:_______ Fax:______
Completed form must be faxed to Risk Management at 706-1520 within 24 hours.
** Attach detailed estimates if available
Insurance Programs
Return to Risk Management
|
