NOTICE OF INCIDENT
(Record Only)
Revised:  06/01/07

This form must be completed when a claim is not expected for personal injury or property damage. It is for record only and should be completed as soon as practical after the occurrence, but within ninety (90) days of the occurrence. File the form with:

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

Full Name____________________________ Phone No(s)___________________________________________________________________
 

__________________________________________________________________________________________________________________
Mailing Address (Include city, state, zip code)

Amount of damages (if known) $________

Describe WHERE, WHEN, and HOW the damages or injury occurred. Include names of all persons involved and any witnesses, including their addresses and telephone numbers.

Location of the Occurrence: ___________________________________________

Date of Occurrence:_____________ Approximate Time:_____________

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 on this form are true and correct to the best of my knowledge.

Date ______________ Signature of Person Reporting___________________________________________

Daytime Phone No. ________________________
 

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