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5. Form Instructions
   Use this form to file a claim against the City of Rockville (City), 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 Risk Management Division will file a claim through LGIT and will email you with your individual claim number and the adjusters 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.
7. Time & Date of Accident*
   Time & Date of Accident

   Time & Date of Accident
9. Location of Accident*
11. Responding Police Department*

    1. Rockville City
    2. Montgomery County

    1. Other
    2. No Police Responded
12. Police Report Number
14. Description of Accident*
16. Upload File - Police Report or Photo
17. Upload File - Photo
18. Upload File - Photo
20. Upload File - Vehicle Registration*
21. Upload File - Quote 1*
22. Upload File - Quote 2
24. Your Name (First & Last)*
25. Your Full Address*
27. Your Email Address*
28. Your Phone Number*
30. Your License Plate Number *
31. Your Vehicle Year, Make & Model*
33. Description of Damage to Your Vehicle*
35. Was Your Vehicle Towed?*

    1. Yes
    2. No
36. If Towed, Where is Your Vehicle being Stored?
38. Was Driver or Passenger Injured?*

    1. Yes
    2. No
39. Is there a Claim with Your Insurer?*

    1. Yes
    2. No
41. Name of Insurance Company
42. Claim Number
43. Adjuster Name & Phone
45. Description of City Vehicle
46. City Vehicle Number
48. Name of City Employee Involved in Accident
50. Next Steps
    Upon completing the form, a representative from the City's Safety & Risk Management Division will email you within two business days with your claim information.
52. Terms & Conditions*

    1. Agree

    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.
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field