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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.

Completion of the Notice of Claim initiates the claim process with the Maryland State Treasurer's Office.

  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, College Park".
  6. Amount of Damages is an estimated amount which may need to be determined.
  7. Include the name, address and telephone number of the individual that caused the loss, if that information is available.
  8. For Description of Incident, provide a complete description of what caused your loss. Attach supporting documents:
    • Three estimates for vehicle damage
    • A list of damaged articles and estimated costs
    • Tow or rental charges
    • Medical bills
    • Police report of other information if applicable

Include any photographs of the damages and forward with additional paperwork.

The Notice of Claim form must include an original signature. An electronic signature will delay the processing of your claim.

Please send completed form and documentation to the State Treasurer's Office noted on the Notice of Claim. Documents may be emailed, faxed or mailed. A copy should also be sent to:

Insurance Coordinator
Environmental Safety, Sustainability and Risk
University of Maryland
Seneca Building #812
4716 Pontiac Street, Suite 0103
College Park, Maryland 20742-3133

Telephone: (301) 405-3961
FAX: (301) 314-9294

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