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Insurance Claim Form

Please print a duplicate copy for your records

Today's Date: Department Name:
Contact Name: Telephone:
Contact E-mail: Location of Accident:
Date of Accident:
Nature of Claim:
Theft
Damage

Description of how loss occurred:

Items Lost:

Item One:
Description of Item:
Date of Purchase:
Where Purchased:
Brown Inventory #:
Original Purchase Price:
Purchase Order #*:
Salvage Attempt - Repair Estimate/Quote:
Replacement Cost**:

Item Two:
Description of Item:
Date of Purchase:
Where Purchased:
Brown Inventory #:
Original Purchase Price:
Purchase Order #*:
Salvage Attempt - Repair Estimate/Quote:
Replacement Cost**:

Item Three:
Description of Item:
Date of Purchase:
Where Purchased:
Brown Inventory #:
Original Purchase Price:
Purchase Order #*:
Salvage Attempt - Repair Estimate/Quote:
Replacement Cost**:

Item Four:
Description of Item:
Date of Purchase:
Where Purchased:
Brown Inventory #:
Original Purchase Price:
Purchase Order #*:
Salvage Attempt - Repair Estimate/Quote:
Replacement Cost**:

*Please provide photocopy of Purchase Order or original purchase receipts to show Brown's ownership.
**If deemed non repairable, must submit original document from service provider.
Submit documentation to The Insurance Office, Box 1848, Fax 3-1566, Phone 3-1681.