Submit a Damage or Injury Claim

Public Claims

Unfortunately, events do occur which may require you to file a claim against the city for damages caused to your automobile or property and even for injuries sustained.

Please select the form below that is most appropriate for the type of claim you are submitting. The city will strive to file your claim as soon as it is received. The city’s Safety and Risk Management Division will email you within two business days with your claim information. For any questions regarding the claims process, please contact claims@rockvillemd.gov.

If you have sustained damages and if this is not a notice or report only claim, the city will file your claim through our primary liability and automobile insurer, the Local Government Insurance Trust. The city’s Safety and Risk Management Division will email you your individual claim number and the insurance adjuster’s contact information.

Note: The city does not directly administer claims and any determinations regarding the acceptance or denial of any claims for damages will be the responsibility of the insurer, the Local Government Insurance Trust.

Use this form to file a claim against the City of Rockville, and our insurer the Local Government Insurance Trust (LGIT), if you believe the city should be legally liable for damage caused to your vehicle or personal injury resulting from an automobile accident. The city will accept this form as meeting the notice provision Section 5-304(b) of the Maryland Local Government Tort Claims Act (LGTCA). Upon submitting your form, the city’s Safety and Risk Management Division will file a claim through LGIT and email you your individual claim number and the adjuster’s contact information. LGIT will handle all aspects of the management of your claim on behalf of the city and will make all determinations regarding the acceptance or denial of any claims for damages.

Date of Accident(Required)

Time of Accident(Required)

Location of Accident(Required)

Responding Police Department(Required)

Police Report Number

Description of Accident(Required)

Police Report

Max. file size: 100 MB.

Upload up to three photos.

Drop files here or

Max. file size: 100 MB, Max. files: 3.

Vehicle Registration(Required)

Max. file size: 100 MB.

Quote 1(Required)

Max. file size: 100 MB.

Quote 2

Max. file size: 100 MB.

Your Name(Required)

First Last

Your Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Email(Required)

Your Phone(Required)

Your License Plate Number(Required)

Your Vehicle Year, Make, and Model(Required)

Description of Damage to Your Vehicle(Required)

Was your vehicle towed?(Required)

Yes

Where is your towed vehicle being stored?

Was the driver or passenger injured?(Required)

Yes

Is there a claim with your insurer?(Required)

Yes

Name of Insurance Company

Claim Number

Adjuster Name

Adjuster Phone Number

Description of City Vehicle

City Vehicle Number

Name of City Employee Involved in Accident

I hereby affirm the information provided is accurate to the best of my knowledge and that I am the legal and registered owner of the vehicle that was damaged. I also acknowledge that the City of Rockville does not administer claims, and rather will file this claim through their insurer, LGIT.(Required)

Agree

Use this form to file a claim against the City of Rockville, and our insurer the Local Government Insurance Trust (LGIT), if you believe the city should be legally liable for damage caused to your property as the result of a sewer backup originating from a city-maintained sewer line. The city will accept this form as meeting the notice provision Section 5-304(b) of the Maryland Local Government Tort Claims Act (LGTCA). Upon submitting your form, the city’s Safety and Risk Management Division will file a claim through LGIT and will email you your individual claim number and the adjuster’s contact information. LGIT will handle all aspects of the management of your claim on behalf of the city and will make all determinations regarding the acceptance or denial of any claims for damages.

Date of Sewer Backup(Required)

Time of Sewer Backup(Required)

Did you call the city’s Public Works Department to report this backup?(Required)

Yes

Date of Notification to Public Works Department(Required)

Time of Notification to Public Works Department(Required)

Who did you report this to in the Public Works Department?(Required)

Provide the name(s) of the city employee(s) who responded to your home.(Required)

Location of Backup(Required)

Have you had a sewer backup at this property previously?(Required)

Yes

Description of Loss or Property Damage(Required)

Upload up to four photos.

Drop files here or

Max. file size: 100 MB, Max. files: 4.

Upload up to two quotes or invoices.

Drop files here or

Max. file size: 100 MB, Max. files: 2.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Is there a claim with your homeowners insurer?(Required)

Yes

Do you have sewer backup endorsement on your homeowners insurance policy?(Required)

Yes

Name of Insurance Company

Claim Number

Phone

Adjuster Name

Adjuster Phone Number

I hereby affirm the information provided is accurate to the best of my knowledge and that I am the legal and registered owner of the property damaged. I also acknowledge that the City of Rockville does not administer claims, and rather will file this claim through their insurer, LGIT.(Required)

Agree

Use this form to file a claim against the City of Rockville, and our insurer(s), if you believe the city should be legally liable for damage caused to your person or property. The city will accept this form as meeting the notice provision Section 5-304(b) of the Maryland Local Government Tort Claims Act (LGTCA). Upon submitting your form, the city’s Safety and Risk Management Division will file a claim through our insurer and will email you your individual claim number and the adjuster’s contact information. The city’s insurer(s) will handle all aspects of the management of your claim on behalf of the city and will make all determinations regarding the acceptance or denial of any claims for damages.

Date of Loss(Required)

Time of Loss(Required)

Type of Claim(Required)

Location of Incident(Required)

Responding Police Department(Required)

Police Report Number

Please provide a thorough description of the incident and subsequent damages you sustained for which you believe the city to be legally liable.(Required)

Police Report

Max. file size: 100 MB.

Upload up to three photos.

Drop files here or

Max. file size: 100 MB, Max. files: 3.

Upload up to two quotes or invoices

Drop files here or

Max. file size: 100 MB, Max. files: 2.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Is this a personal injury claim?(Required)

Yes

Do you have an attorney?(Required)

Yes

Is there a claim with your insurer?(Required)

Yes

Name of Insurance Company

Claim Number

Adjuster Name

Adjuster Phone Number

Agree

Employee Claims

City of Rockville employees are required to report work-related injuries sustained to employees or volunteers by the end of the business day on which the incident occurs. Serious injuries must be reported as soon as practical to the Safety and Risk Management Division. Serious injuries are considered any treatment requiring inpatient hospitalization, amputation, loss of an eye, or fatality.

Use the First Report of Injury Form to report all work-related injuries sustained to employees, temporary employees, or volunteers, or to report any injuries sustained to visitors while in our facilities.

First Report of Injury Form

Use the Non-Injury Report Form to file reports with the Safety and Risk Management Division for the following types of incidents: damage to city property, graffiti, city tree falling down and damaging property, reports of uneven sidewalks, potholes, lost city-owned property, and other public safety hazards.

Non-Injury Report Form

Submit a Damage or Injury Claim

Public Claims

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