NOTICE OF CLAIM
Personal Injury or Property Damage
Last Revised: 06/01/07

This notice should be completed as soon as practical after the occurrence. If it is not completed within ninety (90) days of the occurrence, the claim may be denied based on improper notice. The completed form must be submitted to:

The University of New Mexico
Department of Safety and Risk Services
137 Onate Hall
Albuquerque, New Mexico 87131-3182

Full Name_________________________________________Phone Number(s)____________

Mailing Address (City, State, Zip Code) ____________________________________________

Amount of claim against the University (if known) $ ________

Describe WHERE, WHEN, and HOW the damages or injury occurred and why you feel the University is responsible for your loss. Include names of all persons involved and any witnesses, including their addresses and telephone numbers.

Date of Occurrence:___________________ Approximate Time: __________________

Location of the Occurrence:_______________________________________________

Description of the Occurrence: ________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Describe the injury or damage you sustained and attach copies of all medical reports, bills, or estimates of repairs.
__________________________________________________________________________________

__________________________________________________________________________________

All of the statements made in this claim are true and correct to the best of my knowledge.

__________________________________________________________________________________
Signature of Claimant(s)/Date  

Comments may be sent to UBPPM@UNM.edu
http://www.unm.edu/~ubppm