Insurance Theft/Loss Report Form

Please complete this form, print and forward to Victoria Hogue of the Business Office.  You must save this form to your Directory or the information will be lost.

  1. Please provide the following contact information:

    First Name
    Last Name
    Title
    Organization
    Phone
    FAX
    E-mail
    Other

  2. Received in Business Office: (to be completed by Business Office)

    Name
    Date

  3. Please provide the following claim information:

    Item
    Model
    Product Code
    Serial Number

  4. Choose one of the following options:

     

  5. Enter the date discovered ... : -- mm/dd/yy

     

  6. Enter the date police report was filed (if applicable) ... : -- mm/dd/yy

     

  7. What was the original cost of the item ... ?

     

  8. What is the replacement cost or repair cost ... ?

     

  9. Enter the Budget Code that the item was originally purchased below.

     

  10. Enter the original Account Code ... ?

     

  11. Enter original Budget & Account Code description in the space provided below.


  12. Enter Budget line you will be using to replace or repair the item ... ?

     

  13. Enter the account code you will be using to replace or repair the item ... ?

     

  14. Enter the Budget and Account Code description that you will be using to replace or repair the item in the space provided below.

  15. Please provide the following signatures after this form has been printed:

    Name: Date: -- mm/dd/yy

    Building Administrator: Date: -- mm/dd/yy

 
Financial Services Department
Copyright © 1999 [North Allegheny School District]. All rights reserved.
Revised: 02/13/09