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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 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 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. Date & Time of Sewer Backup*
   Date & Time of Sewer Backup

   Date & Time of Sewer Backup
8. Notice to DPW*

   1. Yes
   2. No

   Did you call the City's Department of Public Works (DPW) to report this backup?
10. Location of Backup*

    1. Mainline
    2. Lateral
    3. Unknown
11. Prior Sewer Issue?*

    1. Yes
    2. No

    Please indicate if you have had a sewer backup at this property previously.
12. Date & Time of Notification to DPW
    Date & Time of Notification to DPW

    Date & Time of Notification to DPW
14. Who did you Report this to in DPW?
15. Who Responded to your Home?
    Please write the name(s) of the City employee(s) who responded to your home.
17. Description of Loss or Property Damage*
    Please provide a thorough description of the extent of your claim for damaged property.
19. Upload File - Photo
20. Upload File - Photo
21. Upload File - Photo
23. Upload File - Photo
24. Upload File - Quote or Invoice
25. Upload File - Quote or Invoice
27. Your Name (First & Last)*
28. Your Full Address*
30. Your Email Address*
31. Your Phone Number*
33. Is there a Claim with Your Homeowners Insurer?*

    1. Yes
    2. No
34. Do you have Sewer Backup Endorsement on your Homeowners Insurance Policy?*

    1. Yes
    2. No
36. 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 property 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