Notice Of Property Loss Form - Department Of Administrative Services, State Of Georgia
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1State of Georgia
Department of Administrative Services
Risk Management Services
NOTICE OF PROPERTY LOSS FORM
IMPORTANT: Use this form to report Property loss that occurs "after hours" ONLY. After
HOURS is referred to as after normal business hours Monday through Friday, 8:00 am to 5:00
pm.
During Business Hours ALL KSU LOSSES -
REPORT to Janet Nash KSU Risk Management
EMERGENCY CONTACT:
678-797-2460 jhull@kennesaw.edu
AFTER HOURS-
Frederick Trotter
LARGE LOSS ONLY TO: :
DOAS Risk Management
404-822-7733
PROVIDE THE FOLLOWING INFORMATION:
TYPE OF LOSS:
(__) Windstorm
(__) Flooding
(__) Other
Date of Loss: __ /__ /__
Time of Loss: ____ AM/PM
Loss Location: ______________
If multiple locations are affected, please attach complete list of each location.
Your Agency: __________________________ Department: _______________________
Agency Ref. #: _____________ Agency Contact & Phone Number: ____________________
Type of Damages: ________________________________________________________
Loss Description
: ________________________________________________
(REQUIRED)
_____________________________________________________________________
_____________________________________________________________________
ESTIMATED LOSS AMOUNT: _______________________________
An acknowledgement letter will be sent to the risk manager with the assigned DOAS claim
number that must be included on the Sworn Proof of Loss form and any other claim related
correspondence.
The DOAS retains the right to assign an outside adjuster to investigate the loss on its behalf.
The Sworn Proof of Loss form with DOAS claim number, copies of original invoices for
property, bills for material and labor and evidence of payment (check or approved purchase
order) for replaced or repaired items must be provided to finalize a claim with in 120 days. The
required documents substantiate reimbursement of damages for a claim.
________________________________________
__________________________
AGENCY RISK MANAGER/COORDINATOR
DATE
_____________________________
__________________________
PHONE NUMBER
FAX NUMBER
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