Generic Liability Loss Report Form

Please complete the form below to report any troubling incident, threatened litigation or actual litigation (Attorney Representation Letter or Service of Suit) associated with any of the threats listed below.

Liability Claim Form for General Liability (GL), Educator’s Legal Liability (ELL), and Automobile Liability (AL) Examples:

- A parent, guardian or guest threatens to sue the district.
- An employee threatens to sue the district.
- A student is injured (a student injury form must also be submitted).
- The district is involved in a bus accident
- At an external event connected to the district:
  - An employee arrested for actions allegedly associated with the district.
  - Any off campus, district sponsored, event where a person is injured.
- Internal events that could result in negative impact to a person’s physical and or financial well-being.

Auto Liability when the district is involved in a bus accident, it may require up to 4 additional Claim Forms:

- Generic Liability (in the case of a lawsuit filed) Complete Claim Form below
- Property (if bus has been damaged) Click Here for Property Claims Form
- A student is injured Click Here for Student Accident Claims Forms
- Workers’ Comp (if employees are injured) Click Here for Workers’ Comp Claims Forms

Generic Liability Loss Report Form

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This field is for validation purposes and should be left unchanged.
Please indicate type of claim:
- Incident Report Only (Troubling Circumstance Without Threat of or Formal Litigation)
- Making a Claim (Received Threat of Litigation, Attorney Representation Letter or Service of Suit)
JIF:
- ACCASBO
- BCIP
- GCSSD
Member District*
Address with City, State & Zip*
Claimant's Name: (Enter Unknown if you don't have the Claimant's name.)*
Claimant's Contact Information:
District Contact Name:*
District Contact Person's Telephone Number:*
District Contact Person's Email:*
Date of Incident:
Date Reported:
Incident Description:
Incident Discovered By Whom:
By What Means:
Approximate Duration of Incident:
Suspect(s) if known, and Date(s) of Employment and/or Department:
Investigating Law Enforcement Agency and/or Jurisdiction:
Charges Filed?
Other(s) Involved:
Attorney's Name and Contact Information:
Supplemental Documents
Upload supplemental docs relating to this claim here.
Max. file size: 2 GB.

For Questions or Issues contact:

Patrick J. Madden, Esq., JIF Solicitor
Law Office of Patrick J. Madden, LLC
204 Glenwood Ave.Haddonfield, NJ 08033
pjm@pjmaddenlaw.com
609-413-5635

Ms. Barbara Maclean, Qual-Lynx Liability Unit Supervisor
Office: 609-833-2916
Fax: 609-601-3188
bmaclean@qual-lynx.com

Chris Roselli, Qual-Lynx Claims Account Manager
Office: 609-833-2176
Cell: 609-287-8569
croselli@qual-lynx.com

JIF Administrators:

Craig Wilkie
Phone: (856) 446-9128
Email: craig_wilkie@rpadmin.com

Scott Tennant
Phone: (856) 446-9181
Email: scott_tennant@rpadmin

School Pool for Excess Liability Limits

Joint Insurance Fund

Generic Liability Loss Report Form

Generic Liability Loss Report Form