Date:

Department Suffering Loss:

Type of Loss:

Please put an X.

Items Damaged or Stolen:

Description of Loss or Damage:

(If lost, Location of item when last seen)

Approximate Dollar Amount of Loss or Damage:

Report Submitted by and phone:

Who should be contacted for further information?

Address and Phone:

Could anything have been done to prevent the damage or loss?

What could be done in the future to prevent similar damage or loss?

***************FOR RISK MANAGEMENT USE ONLY**************

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Policy Date:

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