Property Loss Reporting Form – Insurance & Risk Management

Contact Person*

First Last

Contact Email*

Was the loss discovered by you?*

Loss reported by Name

First Last

If different than contact person

Loss reported by Email

Department or College*

Division*

Report Date*

Date of loss*

Enter date found missing if unknown

Building Name*

Damage Estimate (dollar amount)*

Enter the approximate value of the item(s) lost.

Address*

Street Address Campus Box City State ZIP Code

Description of loss*

What was damaged or lost, cause, surge protection in-place, corrective action, attached reports, photographs, etc.

Actions taken to remediate or prevent further loss

Need to attach pictures / documents?*

Upload Document / Pictures

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, , Max. file size: 64 MB, Max. files: 5.

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