CLAIM FORM TO BE USED FOR UNIVERSITY PROPERTY LOSSES

(Please Type or Print Legibly in Black Ink)

• Date: ___________________________
  
  
• Name of Department: _____________________________________________________
  
  
• Name and phone number of contact person in Department: _______________________
  
  _______________________________________________________________________
  
  
• Date of Loss: _____________________________
  
  
• University Police Report Number: ___________________________________________
  
  
• Location of Loss: ________________________________________________________
  
  
• Description of the loss occurrence (who, what, where, when, etc.):
  
  _______________________________________________________________________
  
  _______________________________________________________________________
  
  _______________________________________________________________________
  
  _______________________________________________________________________
  
  
• Description of equipment or other items lost or damaged. Please include serial numbers,
  N.U. Tag numbers, manufacturer name and model number and the common name of the equipment (computer, printer, projector, etc.):
  
  _______________________________________________________________________
  
  _______________________________________________________________________
  
  _______________________________________________________________________
  
  
• Indicate Department CUFS number to be reimbursed: ___________________________
  
  
• Attach copies of invoices and/or purchase orders for equipment lost or damaged.
  
  
• Attach copies of invoices and/or purchase orders for equipment replacing lost or damaged items.
  
  
• Make sure to keep a copy of all claim documents for your records.
  
  
• Return this form, within 30 days of the date of loss, with all attachments to the Office of Risk Management, 2020 Ridge Avenue, Suite 240, Evanston Campus. Claims received after 30 days of the date of loss will not be accepted. If all information for attachments is not available within 30 days, submit the claim form regardless and include an explanation of why information is not available.
  
  
• Upon receipt of this claim, the Office of Risk Management will issue a claim number to the contact person identified above. This serves to acknowledge receipt of the claim. If the contact person does not receive a confirming claim number within 10 days of submitting this form, he or she should contact the Office of Risk Management to make sure the claim was received.