Claim Form

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Name*

First Name

Last Name

Local Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Permanent Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Email*

Phone*

Reason for filing claim*

Injury Property Damage

Check all that apply

Did you report the incident to the police or tell any other person about it?*

Yes No

INJURY

Date of injury*

Time of injury*

Place of injury*

List of witness names, addresses, and phone numbers*

Describe how the injury happened*

Did you seek medical treatment as a result of this injury?*

Yes No

MEDICAL TREATMENT

Name of medical service provider*

Address of medical service provider*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

List all dates of treatment*

Description of treatment*

Cost of treatment to date* $

Upload one PDF file containing all medical receipts

No File Chosen

File uploads may not work on some mobile devices.

Are you requesting reimbursement for your medical expenses?*

Yes No

PROPERTY DAMAGE

Describe the property that was damaged*

How was your property damaged?*

Date of damage*

Place damaged occurred*

My property was:*

Repaired Replaced I did not repair/replace my property

What was the cost to repair/replace your property?* $

Upload one PDF file containing all damage receipts or estimates

No File Chosen

File uploads may not work on some mobile devices.

Are you requesting reimbursement for your property damage?*

Yes No

REPORTING THE INCIDENT

Name of person or office to whom you reported the incident*

Address or campus location of person or office to whom you reported the incident*

Phone number of person or office to whom you reported the incident*

Date incident was reported*

Police Report Number (if applicable)*

REIMBURSEMENT

What is the total amount of reimbursement you seek from Lamar University?* $

Explain why you believe this amount is due you*