Office of Risk Management

Property Loss Report

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 AcquiredRepl. 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:
DescriptionDescription
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Labor Total $___________________________Materials Total $_________________________


Other:

Description:Labor:$____________________
______________________________________Materials:$____________________
______________________________________Other$____________________
______________________________________
Other Total $____________________________Total Cost$____________________


____________________________________________________________________________
Date of ReportSignature of Person Filing this ReportYour Department Name