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

   Time & Date of Loss
8. Type of Claim*

   1. Personal Injury
   2. Property Damage

   1. Notice or Report Only
   2. Other Claim

   Please select the type of claim you are filing.
10. Location of Incident*
12. Responding Police Department*

    1. Rockville City
    2. Montgomery County

    1. Other
    2. No Police Responded
13. Police Report Number
15. Description of Incident*
    Please provide a thorough description of the incident and subsequent damages you sustained for which you believe the City to be legally liable for.
17. Upload File - Police Report
18. Upload File - Photo
19. Upload File - Photo
21. Upload File - Photo
22. Upload File - Quote or Invoice
23. Upload File - Quote or Invoice
25. Your Name (First & Last)*
26. Your Full Address*
28. Your Email Address*
29. Your Phone Number*
31. Is this a Personal Injury Claim?*

    1. Yes
    2. No
32. Do you have an Attorney?

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

    1. Yes
    2. No
35. Name of Insurance Company
37. Claim Number
38. Adjuster Name & Phone
40. 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.
42. 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:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field