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CLAIM FORM FOR PROPERTY AND/OR CONTENTS DAMAGE / LOSS Date of Incident : _ _ / _ _ / _ _ Time : _ _: _ _ A.M. / P.M. School:_____________________ Department: __________________________ Location of Incident : Building (name) : _________________________________ Floor / Room / Lab # ______________________________ Street : _________________________________ City State Zip : _________________________________ Contact Person : _________________________________ Detailed Explanation Of Incident: Cause: __ Fire __ Flood __ Explosion __ Equipment Failure (specify:_____________) __ Storm / Wind/ Lightening __ Vandalism __ Other _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Estimated Property (Building) Loss / Damage : $______________ ** Estimated Contents Loss / Damage : $_______________ **UMB Police Report #_________ Fire Dept Report #___________ Name of person completing form: ___________________________ Phone:_______ Fax:______ Completed form must be faxed to Risk Management at 706-1520 within 24 hours. ** See attached inventory sheets for compiling lists of damaged / destroyed supplies and / or equipment. Be specific and include make, model, and optional features. DO NOT DISPOSE OF ANY ITEMS UNTIL INVENTORY HAS BEEN ACCEPTED AND APPROVED BY RISK MANAGEMENT. DAMAGED / DESTROYED CHEMICALS, BIOLOGICALS , OR ANIMAL REMAINS / SAMPLES MUST BE DISPOSED OF BY WASTE MANAGEMENT AFTER INVENTORY HAS BEEN APPROVED. Return to Risk Management |
