Small Claims Incident Report

^* Required Information

Part 1 - PERSONAL INFORMATION

Name of person involved*

First Name

Last Name

UB Person Number (or last 4 digits of Social Security Number if not from University at Buffalo)*

Email*

Department (if applicable)

School Address

Department Address (if applicable)

Forwarding Address (End of Semester)

Include Zip Code

Department Phone (if applicable)

(xxx)-xxx-xxxx

Home Address*

Include Zip Code

Supervisor's Name (if applicable)

First Name

Last Name

Home Phone*

(xxx)-xxx-xxxx

Mobile Phone

(xxx)-xxx-xxxx

Status*

Employee Student Visitor

Part 2 - INCIDENT DETAILS

Date/time of incident*

Date/time Notified Supervisor*

Is a report filed with University Police?*

Yes No

Date of Police Report*

Location of Incident*

For Example: campus, building name, street name, nearest landmark

Describe the incident in detail. What happened? *

State in detail all known facts and circumstances, identify persons and property involved.

Attach Supporting Documents (1)

No File Chosen

File uploads may not work on some mobile devices.

Attach photos, charts, maps, diagrams, etc. to help EH&S understand the incident.

Attach Supporting Documents (2)

No File Chosen

File uploads may not work on some mobile devices.

Attach photos, charts, maps, diagrams, etc. to help EH&S understand the incident.

Attach Supporting Documents (3)

No File Chosen

File uploads may not work on some mobile devices.

Attach photos, charts, maps, diagrams, etc. to help EH&S understand the incident.

Describe any act of condition that may have contributed to the incident, including any equipment or materials:*

Explain why you feel the University is negligent:*

Witnesses to Incident/Injury/Damage/Loss

Witness 1 Name

Witness 1 Address

Witness 1 Phone

Witness 2 Name

Witness 2 Address

Witness 2 Phone

Property Damage or Loss Description*

Detailed description of items and extent of loss

Part 3 - AMOUNT OF CLAIM - ESTIMATED VALUE

Instructions:

You must state a dollar amount on the form. If your claim is accepted by the State, the dollar amount of your claim will need to be documented by independent verification and evidence. The following are examples of acceptable means of independent verification or documentation to be submitted after claim is accepted by the State:

• For stolen or for property that has been damaged, attach the following to support your claim:

• A sales receipt
• A copy of the credit card billing statement indicating the amount paid.
• A copy of the front and back of a canceled check used to pay for the item.
• A copy of the money order receipt if the money order was used to pay for the item.

Please Note: The State is not obligated to pay replacement value for damaged personal property and the Attorney General will disapprove any small claim that does not reflect a reasonable amount of depreciation. If necessary, depreciation will be factored into the dollar amount of the claim.

• For damage to a vehicle, provide:

• Photographs

• Copy of Driver's License
• Copy of Vehicle Registration
• Two (2) vehicle estimates of repair from a collision shop.

Please Note: You may subrogate your claim through your insurance company or directly. If approved, the claim will be paid to the insurance company (if subrogated) or to the collision shop.

I am reporting more than 6 items*

Yes No

The claim form is designed to list six items. If additional space is needed, attach an itemized list to support claim:*

No File Chosen

File uploads may not work on some mobile devices.

List each item, original cost of the item, date purchased, where purchased and the value of the item

Property Damage/Loss (in dollars)*

Date Purchased*

Certification

Please be advised that the liability must be shown to be directly caused by the act or omission on the part of a state officer or employee as described in the claim. Damage caused by “an act of God” or other accidental occurrence which is not caused by the negligence or breach of duty by a state officer or employee is not the State University’s responsibility. The individual causing the damage must be an officer or employee of the State of New York, not an independent contractor, for the State University to be liable. The State is not obligated to pay replacement value for damaged personal property and the Attorney General will disapprove any small claim that does not reflect a reasonable amount of depreciation. Therefore, depreciation will be factored into the dollar amount of the claim.

The State is not automatically responsible for bills (medical, repairs or other) simply because the incident occurs on its premises or as a result of its operations. It is your responsibility to fulfill your financial obligations. Also, the Small Claims process does not cover damage related to potholes.

One purpose of this reporting process is to identify and avoid other potential incidents which could harm other persons or damage property. After submitting this form, you may be contacted by the EH&S Small Claims Administrator, University Services or University Police for additional information. You should not discuss or provide information to anyone other than the above-mentioned offices. Completing this form will also assist the University in identifying possible corrective action to avoid further incidents.

By clicking on "I Agree", I understand that filing any false statement on this Incident Report may subject me to civil and/or criminal penalties.*

I Agree