Risk Management Potential Property Claim Form
Risk Management Potential Property Claim Form
To. Risk Management, Phone (859) 257-3708
306 Peterson Service Building, Fax (859) 257-1050
Lexington, Kentucky 40506-0005 Email:llrook00@email.uky.edu
FROM: ___________________________________________________ DATE:_________________________
SUBJECT: Potential Property Claim, Police Report No. _______________
Please indicate below the type of policy associated with your loss. Deductibles indicated are per occurrence.
_____ Crime Policy - $100,000 deductible. Includes cash and damages or theft of property during the theft of cash.
_____ Computers - $5,000 deductible for all perils.
_____ Inland Marine - $5,000 deductible. Items are scheduled for coverage by department.
_____ Property/Other - $5,000 deductible. Values by Building Inventory Locations.
In order to process the above potential claim, the following information is needed. Please indicate if attached.
_____ Purchase Document(s) of equipment stolen, damaged, etc,. or Inventory Records
_____ Repair Estimates/Invoices
_____ Purchase Documents of replacement equipment or written quote for replacement cost
_____ Other/Comments: ____________________________________________________
Location of Incident
Building No.: _____________ Building Name: ______________________________________
Department No.: __________Dept. Name: __________________________________________
Person Reporting Loss: _________________________ Contact Person: _____________________
Estimated Amount of Loss: ______________________ Job Order No. _______________________
Cause: ____________________ (water, fire, wind, lightening, vandalism, theft, etc.)
Description of Loss _________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
We need complete itemized description of materials and labor. If you have any questions, please call us at 257-3708. Revised 7-13-17
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