BYUH Property Damage-Loss Report
BYU Hawaii Human Resources
55-220 Kulanui St. #1969
Laie, HI 96762
Phone: (808)293-3675 Fax: (808) 293-3657
Claim no. (Provided by Human Resources)
General Information
Item damaged or stolen (complete name of department)
Department Account #:
Department Box# / phone number
Property number
Name and title of contact person
Date and time of loss/ damage
Date reported to Risk Management
Complete address of contact person
Telephone number
Fax number
Email
Name and title of police investigating officer/BYUH security officer
Case or file number
Summary of Loss
Contents (items listed in the PRG- include Information System Order form if loss includes damage to computers)
Contents replacement cost
(Itemized from the reverse side of this form)
$
Facility
Structural repair cost
(Itemized from the reverse side of this from)
$
Provide a summary of facts and circumstances. Attach photographs when appropriate
Forcible Entry
Yes Describe how acces was gained
No Explain why the building was not secured
Preventive Action
(NOTE:
this section must be completed)
What measure have been taken to prevent a recurrence?
Signatures
(Signatures verify that all costs are directly related to the loss without betterment or enhancement
Name of facilities or department manager (please print)
Telephone
Signature of facilities or department manager ($0-$25,000)
Date
Signature of regional manager or department controller ($25,001-$100,000)
Date
Contents
(List by item, and enclose purchase requisitions)
PRG item
number
Quantity
Account
Category
Replacement
cost
See accounting codes
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Contents total
$
Structural damage
(List by major types of work, provide a copy of bids(s) or estimate(s).
One bid $2,000-4,999; two bids $5,000-100,000)
Estimated
payment date
Account
Category
Bid amount
See accounting codes
A
B
C
D
E
F
G
Structural total
$
Contents and structural total
$