Liability & Errors-Omissions/IEP Loss Notice
	Member Section Supervisory Union SU Contact Phone choose one Addison Central Addison Northeast Addison Northwest Addison Rutland Barre Battenkill Valley Blue Mountain Colchester Franklin Central Franklin Northeast Franklin West Lamoille North Montpelier Orange East Orange North Orange Southwest Orange Windsor Orleans Central Orleans Southwest Orleans-Essex North Patricia A. Hannaford Career Center River Valley Technical Center Rutland Central Rutland Northeast Rutland South Rutland Southwest South Burlington Springfield Washington Northeast Washington West Windham Northeast Windsor Central Windsor Southeast Windsor Southwest Winooski () -   SU Contact Person SU Contact Email Loss Section: Injured Persons/Property Damage: Date of occurrence Location of occurrence Description of occurrence Did authorities investigate? Yes   No If Yes, please list name of police dept./governmental entity Were other parties injured? Yes   No Was other property damaged? Yes   No Other: Were there any witnesses to the accident? Yes   No Important information regarding the above: If the answer to any of the previous questions is YES, the adjuster most likely will be requesting the following information. Your assistance in compiling these items will greatly assist in the adjustment of this claim. If you answered YES to the question, "Were other parties injured?", each person's: Name Address Phone Number Age Gender Extent of injury Role in occurence If you answered YES to the question, "Was other property damaged?", each item's: Estimated amount of damage Description Owner If you answered YES to the question, "Were there witnesses to the accident?", each witness's: Name Address Phone number IEP Due Process Claims only: Date notified of grievance Name of student Please summarize the grievance Please summarize the SU's position on the grievance This notice was submitted by: on:
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