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Facilities Management Claim Form

Today's Date: Date of Incident:
Time of Incident: Date Facilities responded:
Location of incident (name of building, street address, etc):
Areas Affected:

Description of how the incident occurred: (example: If you indicate the overhead air handling unit froze, please provide an explanation of how it froze. What was the specific cause?)

Description of resulting damage sustained to Brown's property:

In order for resulting damage to be covered by insurance, there needs to be a specific identifiable cause of loss.
Work Order Number(s):

Estimated value:  
$500 to $1,000 Contact person for this claim:
$1,000 to $4,999 Contact phone number:
$5,000 to $9,999  
$10,000 to $24,999  
$25,000 to $49,999  
$50,000 to $99,999  
Over $100,000  

Status of work performed:
Any other comments?