2. Local Government Insurance Trust
   7225 Parkway Dr.
   Hanover, MD 21076
   443.561.1700

   If you have a question or concern you would like the Trust to address, please submit this form. Please DO NOT request a Certificate of Insurance via Contact Us. Request a COI on the Member Portal or contact your underwriter. DO NOT submit this form to contact CLAIMS. They do not receive this report. We will try to address your request in a timely manner.
4. Contact Information
6. Name*
7. Local Government Name*
9. Phone Number (xxxxxxxxxx)*
10. Title*
12. Email*
14. 
    
16. Departments
18. Which department would you like to contact?*

    1. Executive
    2. Finance & Information
    3. Loss Control
    4. Member Services
    5. Training
    6. Underwriting
20. 
    
22. Questions & Concerns
24. 
    
26. What is the nature of your request?*
28. 
    
30. Would you like to be contacted concerning your request?*

    1. Yes
    2. No
32. 
    
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field