Description of loss (explain what happened):

Please describe any action taken to limit the loss or prevent further damage:

Person at department to contact:
Telephone number:

If this was a theft, were the Police or Protective Services notified? (you must notify the police if a theft has occurred)
Yes No

Did your department purchase Floater Insurance on this property?
Yes No

If yes, what is your department number?

Serial number of the item as it appears on your Floater Insurance schedule:

Name and title of person submitting claim: