Property/Liability Loss Notice
NOTE: If incident involves significant property damage or
serious injury or fatality, please call 651-201-2594 as soon as possible.
Instructions:
1. Use this form for all property and general liability incidents. You may use your own form if it includes all
the requested data.
2. Complete as much information as possible and submit within 24 hours.
3. Submit by email to claims.rmd@state.mn.us (preferred) or by fax: 651-297-7715
4. To report vehicle crash/damage incidents please see mn.gov/admin/risk
Section 1: Insured Entity
Agency/Campus: Address:
Contact person: Email: Phone:
Section 2: Incident Information
Incident date: Incident time: am pm
Location: (address):
City: State:
Additional location details
(e.g. building, room, areas):
Description of the incident (describe what happened just before, during, and after the incident.):
Section 3: Injuries (use additional sheet(s) as needed for other parties as needed.)
Was anyone injured? Yes No
Injured person name: Phone:
Address: Email:
Description of injury:
Section 4: Property Damage (to report vehicle crash/damage incidents please see mn.gov/admin/risk)
Was property damaged? Yes No
Owner name: Phone:
Owner address: Email:
Description of property damage:
Section 5: Person Completing Form
Phone:
Email:
Name:
Date completed:
Date management notified of incident:
CLICK TO SUBMIT FORM BY EMAIL
Property/Liability Loss Notice form ver.2-2017
page 1 of 1
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome