Safety & Loss Prevention
Property Loss Report
(If more space is needed, use back of form.)
Send to: UW System System Risk Management, 780 Regent St., Madison, WI 53715-2635
Campus Name_________________________________________________________________________
Building Name_________________________________________________________________________
Building No.___________________________________________________________________________
Time: Date_________________________________Hour______________________a.m./p.m.
Item(s) Lost:
| U.W. Iden. | Description (Name, Model, Ser.#, Etc.) | Year Acquired | Repl. Cost |
Cause of Loss:_______________________________________________________________________________
If Theft, V&MM, Collision; Police Report Required.
How Loss Occurred:__________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
Description of Damage:________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
Is claim being pursued against third party?__________Yes __________No
If yes; Status of action:_________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
| Labor: | Materials: |
| Description | Description |
| ______________________________________ | ______________________________________ |
| ______________________________________ | ______________________________________ |
| ______________________________________ | ______________________________________ |
| Labor Total $___________________________ | Materials Total $_________________________ |
Other:
| Description: | Labor: | $____________________ |
| ______________________________________ | Materials: | $____________________ |
| ______________________________________ | Other | $____________________ |
| ______________________________________ | ||
| Other Total $____________________________ | Total Cost | $____________________ |
| ________________ | _____________________________________ | _______________________ |
| Date of Report | Signature of Person Filing this Report | Your Department Name |