Property Loss Reporting Form

						Property Loss Report Risk Management Division Phone (704) 336-3301 Fax (704) 336-7548

Please complete as much information as possible. Any field that is preceeded by an "*" is a required field. The form cannot be submitted until all required fields are completed.

*Property Owned By

*Department

*Division

Dept. Code

Called to Risk Management By:

Date:

Time:

Police Report Number

LOSS INFORMATION
*Type Of Loss If "Other" then please list type
*Date of Loss: Time	*Location
*Description of Loss or Damage

NAME OF PERSON(S) CAUSING LOSS OR DAMAGE
*Please select the number of Persons Causing Loss or Damage

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

Name
Address	City/State/Zip / /
Phone Number (Home)	Work Phone Number (Work)

WITNESSES (If any)
*Please select the number of Witnesses you wish to enter

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

Witness Name	Address
City/State/Zip / /	Phone #

NOTE: To collect for any loss, you must provide proof of value and current/completed purchase order or contractors estimates. Please forward this information to Risk Management.

Attach any other additional information you may have to this report. Forward all additional info to Risk Management as it becomes available.


*Supervisor Name	*Phone #	*Date
Employee Email: A copy of this report automatically goes to Risk Management. Please enter any additional email addresses that you desire a copy to go to.
Employee Email: (Separate Multiple Emails by commas)
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