Can be used for any claim except WORKERS’ COMPENSATION
NOTICE OF INCIDENT – STATE OF NEW MEXICO
(Fill out this form in detail)
Please print or type
Location Code: ____________
Dept./Div. ______________________________Div. Address___________________________________
Div. Contact Person _______________________________Phone No. ____________________________
Employee Involved _______________________________Phone No. ____________________________
Date_________________________________Time _____________________a.m. ______p.m.________
Location of Incident ____________________________________________________________________
Full Name___________________________________________________Age______________________
Address____________________________________________________Phone No.__________________
Employed by __________________________________________________________________________
Injuries ______________________________________________________________________________
Treated by ___________________________________________________________________________
Address______________________________________________________________________________
Full Name ________________________________________________Phone No. ___________________
Address______________________________________________________________________________
Description of Property Damaged
Name ________________________________________________________________________________
Address____________________________________________________Phone No. _________________
Name________________________________________________________________________________
Address ____________________________________________________Phone No. _________________

Please describe incident
Date______________________________________
Reported by _______________________________
Dept./Div. ___________________________________________________________________________________
____________________________________________________________________________________________

TORT NOTICE OF CLAIM
41-4-16. Notice of Claims
Every person who claims damages from the state or any local public body under the Tort Claims Act (41-4-1 to 41-4-27
NMSA 1978) shall cause to be presented to the Risk Management Division for claims against the state, the mayor of the municipality for claims against the municipality, the superintendent of the school district for claims against the school district; the county clerk of a county for claims against the county, or to the administrative head of any other local public body for claims against such local public body, within ninety days after an occurrence giving rise to a claim for which immunity has been waived under Tort Claims Act, a written notice stating the time, place and circumstances of the loss or injury.
DATE OF INCIDENT ______________________________________
TIME OF INCIDENT_______________________________________
STATE AGENCY INVOLVED ________________________________
CLAIMANT’S NAME & ADDRESS ____________________________
____________________________
____________________________
PHONE NUMBER ________________________________________
LOCATION OF ACCIDENT _________________________________
Please describe how the incident occurred and why you feel State Agency is at fault:
What are you making claim for: Please check one
____ Bodily Injury ____Property Damage
Please describe injury or property damage:
__________________________________________
Signature of Claimant or lawful representative
Mail claim to: ENMU- Purchasing/Property & Casualty Claims Office
1500 S. Ave. K, Station 50
Portales, NM 88130
Attn: Jane Blakeley
Phone # 575.562.2425 Fax# 575.562.2426