For USTIF to process your claim in timely manner, please follow these instructions.

1. Complete all the fields highlighted in yellow.
2. Save a copy for your records, once completed.
3. Email the form to RA-IN-FBSCLAIMS@PA.GOV with the subject line:
   CLAIM NOTIFICATION SUBMITTAL FORM

If you run into issues, please contact by calling 717-783-8093 and follow the prompts for Claims Department. Thank you.