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EMPLOYEE FIDELITY BOND REPORT OF LOSS 1. UNIVERSITY INFORMATION SCHOOL :________________________ DEPARTMENT:_______________________ CONTACT PERSON:_____________________________ PHONE # :______________ 2. INCIDENT INFORMATION DATE OF INCIDENT : _ _ / _ _ / _ _ DATE DISCOVERED: _ _ / _ _ / _ _ DETAILED DESCRIPTION OF INCIDENT ___________________________________ ____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ LOCATION OF INCIDENT (BUILDING AND ADDRESS) ________________________ _____________________________________________________________________ _____________________________________________________________________ 3. EMPLOYEE INFORMATION (ALLEGEDLY INVOLVED IN INCIDENT)
4. WITNESS INFORMATION :
5. POLICE INFORMATION:
POLICE REPORT # : ______________ AMOUNT OF LOSS : $______________ The submitting of a claim under this Bond is a very serious matter requiring the filing of a formal Police report naming the alleged involved employee(s). Because this claim alleges possible criminal activity on the part of an employee or employees, all information should be kept in strictest confidence to protect the rights of the employee(s). Claim completed and submitted by:
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