UPUD | Claims Tracking

UPUD | Claims Tracking

Claimant Information

First Name*

Last Name*

Phone Number*

Email*

Date of Birth*

Mailing Address

Please enter your mailing address information:

Number and Street (or P.O. Box)*

City*

Zip Code

Service Address

Is your service address the same as your mailing address?*

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Service Address

Service Address City

Service Address Zip

Witness Information

Was there a witness?*

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Witness Name

Witness Phone Number

Witness Email

Claim Information

Please provide the following information with regards to the occurrence or transaction, which gave rise to the claim you are asserting:

Date of Event*

Time of Event*

Place of Event*

Give a general description of the indebtedness, obligation, injury or loss incurred so far as it may be known at the current time when presenting this claim.*

Did a UPUD employee cause injury, damage or loss in relation to this claim?*

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Provide the name or names of the employee or employees.

Attach any photographs or pertinent documents you may have regarding this claim.

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