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Property Loss Notification Form
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Property Loss Notice Form
Date of Loss
*
MM slash DD slash YYYY
Address or location of loss: (please specify building, floor, department, and room number)
Description of loss: (explain what happened)
*
Please describe any action taken to limit the loss or prevent further damage:
Person at department to contact:
Phone Number:
If this was a theft, were the Police or Protective Services notified? (you must notify the police if a theft has occurred)
Yes
No
Did your department purchase Floater Insurance on this property?
*
Yes
No
If yes, what is your department #?
Serial number of the item as it appears on your Floater Insurance schedule:
Name of person submitting claim:
*
First
Last
Email
*
Title of person submitting claim:
*
Email
This field is for validation purposes and should be left unchanged.