Claim Intake Form

Incident/Claim Information

Incident Type

Other Incident Type

Incident Date

MM/DD/YYYY

Did this incident occur in a campus facility

Campus Building Location

Please select the campus building by typing it below (If the building is not listed, choose “No, Off Campus” option above and enter the property location manually.)

Street Address

City

State / Province

Off Campus Location

Incident Location

Please enter the full address here including city, province, postal code & country

Incident Description

UAPS number (if applicable)

Estimated Damages/Losses (CAD$)

Please insert dollar amount only.

Reporter Details

"Reporter" is the person filling out this form

Are you reporting this incident on behalf of yourself or another person?

Please select "Another Person" if you're not the
Claimant and add the Claimant details in the "Involved Person" section below

Are you an Employee or a Student

Please enter your details in this Reporter Details section.

In the Involved Person Details section below, enter the details of the person(s) for whom you are filling out this form.

Did you sustain an injury?

First Name

Last Name

Faculty/Department Name

Job Title

Email

Reporter Address

Street Address

This is a non mandatory field and you can skip this if you wish not to share your personal address

City

Province/State

Country

Zip/Postal Code

Date of Birth

Did you seek medical attention?

Did you receive care from Emergency Medical Services?

Healthcare Provider's Name

Have you received any other medical aid?

Description of Personal Injuries

Do you wish to add Involved Persons?

"Involved Person" is an individual who is/may be involved with the claim/incident (directly or indirectly) being reported. (Examples include the claimant, witness to the incident, lawyer, property manager, employees, etc.)

Involved Person Details

Involvement Type

Did this person sustain an injury?

ContactRecordTypeID

First Name

Last Name

Email

Faculty/Department Name

Job Title

Involved Person Address

Mailing Address

This is a non mandatory filed and you can skip this, if you wish not to share your personal address

Province/State

Zip/Postal Code

City

Country

Date of Birth

Did this person seek medical attention?

Did this person receive care from Emergency Medical Services?

Healthcare Provider's Name

Has this person received any other medical aid?

Description of Personal Injuries

To add another involved person, please select "Add Another Involved Person" on the bottom-right portion of this section.

Vehicle Ownership

Select the type of Vehicle(s) affected

University OwnedOther If you do not know the specific details of the Vehicle, please use "Other "

Campus Owned Vehicles

Vehicle Details

Please enter the UofA Vehicle unit number

Enter the V_ number above , If the vehicle is not showing up -select Other
from the above section and fill the details in the "other vehicle" section.

Vehicle Asset ID

Vehicle Year

Vehicle Make

If make not known, please insert "N/A"

Vehicle Model

License Plate

Description of Damages

Other Involved Vehicle

Note: If you do not know the specific ownership details of the vehicle, please use "Other"

Other Vehicle

Ownership

Vehicle Year

Vehicle Make

If make not known, please insert "N/A"

Vehicle Model

License Plate

Vehicle Name

Description of Damages

To add another Vehicle, please select "Add Another Vehicle" on the bottom-right portion of this section.

Involved Equipment

Note: If you do not know the specific details of the Equipment, please use "Other"

Ownership

Equipment Details

Equipment Name

Equipment Type

Equipment Number

Equipment Description

Description of Damages

To add another Equipment, please select "Add Another Equipment" on the bottom-right portion of this section.

Property Ownership

Select the type of propert(ies) affected

Campus OwnedOther If you do not know the specific details of the Property , please use "Other "

Campus Owned Properties

Campus Building Information

Please select the campus building by typing it below (If the building is not listed, choose “Other” option above and enter the property details manually.)

Street Address

City

State / Province

Description of Loss/Incident/Damage

Other Property

Note: If you do not know the property details, please put "Other"

Ownership

Property Details

Property Name

Street Address

Please enter the full address here including city , province, postal code and country

Description of Loss/Incident/Damage

To add another property, please select "Add Another Property" on the bottom-right portion of this section.

Attachments

Do you wish to add Files/Attachments?

Note: There is a 25 MB per file size limit, a 35 MB total file size limit, and a 10 file limit per submission.

Please upload any supporting documents, images, invoices, or estimate of damages. You can also email or share files directly with erm10@ualberta.ca
File Upload

To add more than one attachment, select "Add Another Attachment". To remove the additional file upload option, select "Remove".

Declaration

Declaration

Protection of Privacy - Personal information provided is collected in accordance with Section 4(c) of the Alberta Protection of Privacy Act (POPA) and will be protected in accordance with section 10 and used and disclosed in accordance with sections 12 and 13 of the Act. It will be used and/or disclosed for the purpose of administering your claim.

Please note that information collected will be transmitted to and stored on servers outside of the University, Alberta and Canada and that the University cannot guarantee protection against disclosures as a consequence of foreign laws.

The University of Alberta uses automated systems to generate content and to make decisions, recommendations, and predictions. The personal information collected may be included in these automated systems. Should you require further information about collection, use and disclosure of personal information, please contact: Risk Management and Insurance at erm10@ualberta.ca

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