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FROM: ___________________________________________________ DATE:_________________________ |
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SUBJECT: Potential Property Claim, Police Report No. _______________ |
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Please indicate below the type of policy
associated with your loss. Deductibles indicated
are per occurrence.
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_____ Crime Policy - $100,000 deductible. Includes cash and damages or theft of property during the theft of cash. |
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_____ Computers - $5,000 deductible for all perils except theft; $7,500 deductible for theft of laptops. |
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_____ Inland Marine - $250 deductible. Items are scheduled for coverage by department special request. |
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_____ Property/Other - $500 deductible/Telephone -$1,000 deductible. Values By Building Inventory Locations. |
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In order to process the above potential claim, the following information is needed. Please indicate if attached. |
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_____ Purchase
Document(s) of equipment stolen, damaged, etc. or Inventory Records |
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_____ Repair
Estimates/Invoices |
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_____ Purchase Documents
of replacement equipment or written quote for replacement cost |
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Other/Comments: ____________________________________________________ |
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Location of
Incident |
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Department No.:
__________Dept. Name:__________________________________________ |
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Person Reporting
Loss: ______________________________ Contact
Person: ________________________ |
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Amount of Loss:
_________________________ Job Order
No. ____________________________ |
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Cause:
____________________(water, fire, wind, lightening, vandalism, theft, etc.) |
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Description of
Loss_______________________________________________________________________ |
We need complete itemized
description of materials and labor. If you have any questions, please
call us at 257-3708.
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Doc Revision date: August 2003
Web page update: August 20, 2003