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:
Department of Safety and Risk Services
1801 Tucker St. NE, Bldg 233 MSC07 4100
1 University of New Mexico
Albuquerque, New Mexico 87131-0001
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