Plano ISD Benefits and Risk Management Department Loss Report Form

Instructions: Losses must be reported as soon as possible. Fill out a separate form for each item involved. This original report detailing the loss will be used for police and insurance reporting. It is very important that all pertinent facts concerning the loss be included and all items below completed.

Loss Report

Name of individual discovering loss:

PISD Location:

Date of loss:

Click to Open Calendar. The Date format is MM/DD/YYYY

Time of loss:

Complete description of item (make, model, etc.):

Date of purchase:

Original cost:

Serial number:

Inventory number:

Location of item when loss occurred:

Account purchased from:

Last date item observed:

Last time item observed:

Last person who observed item:

Area item assigned to:

Police file number:

Type of loss:

Burglary

Theft

Loss (damage from fire, water, etc.)

Vandalism

If burglary or theft, describe any physical evidence or extent of the burglary, or anything out of the ordinary.

If loss or vandalism, describe the type and extent of damage.

Report completed by:

Supervisor:

You will be able to submit this form AFTER you click the Submit/Preview button.