PROPERTY LOSS REPORT

 

 

Print, fill in with your information and send to: Risk Management, University Services, Room 130

 

 

Location of Incident  (building/room)_________________________________________________________________________

 

Time: Date_________________________________Hour______________________a.m./p.m.

 

Item(s) Lost: 

Description	Brand Name/Model	Serial Number	Year Acquired	Replacement Cost

 

 

CAUSE  of  Loss: (If theft, vandalism, collision a University Police Report Required).

 

How Loss Occurred:__________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

 

Description of Damage:________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

 

Is claim being pursued against third party?__________Yes __________No

 

If yes; Status of action:_________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

 

 

 ________________                 ___________________________________                 _______________________

     Date of Report                Signature of Person Filing this Report                 Your Department Name