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Instructions for Completing
Notice of Claim

A Notice of Claim form should be completed each time an individual files a claim or suffers a loss or injury to oneself or to that individual's personal property.

Information should be typed or printed.

1. For Name, address, phone number, include the complete name, address and telephone numbers (home/work). If a campus student or employee, include campus address and permanent address.
2. Date of Loss refers to the date the incident occurred.
3. Location of Loss refers to where the incident occurred.
4. County usually refers to Prince George's County. If out-of-state, include state.
5. State Agency Involved refers to the "University of Maryland".
6. Amount of Damages is an estimated amount which may need to be determined. In that case, just use " N/A ".
7. Include the name, address and telephone number of the individual that caused the loss, if that information is available. If unavailable, use "N/A".
8. For Description of Incident, provide a complete description of what caused your loss. Attach supporting documents:
   • Two estimates for vehicle damage
   • A list of damaged articles and estimated costs
   • Tow charges
   • Medical bills
   • Other if applicable
9. Photographs of damaged property should be taken by the Insurance Coordinator, Department of Environmental Safety. Call (301) 405-3964 to set up an appointment to have photographs taken.

Insurance Coordinator Environmental Safety University of Maryland 3115 Chesapeake Building College Park, Maryland 20742-3133

Telephone: (301) 405-3964 FAX: (301) 405-2391 Email: insurance@umd.edu

Revised October 9, 2003

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