Department__________________________________________ Date ______________

Completed by ________________________________________ Date ______________

Cause of Loss	Type of Loss
 Theft	 Property Damage
 Vandalism	 Inventory
 Burglary	 Money/Cash
 Tools and Equipment	 Tools and Equipment
 Fire/Arson	 Employee Time
 Accident—Damage	 Business Interruption
 Unexplained	 Other: _________________________________________ _________________________________________
 Other: _______________________________________ _______________________________________

Date and time loss occurred _______________________________________________________

Date and time loss reported _______________________________________________________

 Police report made               Report ID # _____________________________________________

List police department contacts and notes ___________________________________________

______________________________________________________________________________

Besides the property loss, were there any other consequences of the loss? _________________

_______________________________________________________________________________

_______________________________________________________________________________

Could this loss have been avoided?      Yes    No

If yes, how? ____________________________________________________________________

______________________________________________________________________________

Other comments, notes: ___________________________________________________________