Fillable Insurance Fund Claim Worksheet

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Insurance Fund Claim Worksheet

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Insurance Fund Claim Worksheet
Replacement of CCSD Supplies and Inventoried Equipment
Location: Location #:
Loss Date: Police Report #:
Claim #:Type of Loss:
Quantity
Lost
Estimated
Cost Per
Item
Approved?
(Completed by RM)
Replacement
Requested?
Item Lost/Damaged - Describe
(Include Make/Model/Serial #, suggested
vendor, etc.)
Page 1 of 3Doc. #RSK-F001, Rev F 17 October 2018
v Make sure you attach a copy of the site inventory list showing the lost or damaged items.
Contact Phone#:
Administrator's Name:
Contact Person:
Claim Total: $
Submission Date:
Location Cost Center:
BELOW SECTION FOR CLAIM ADJUSTER
Administrator Signature
Yes No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Fund:
Deductible Applied?
Yes No
Total $: Reimbursement: $
Claim Adjuster's Name:
Claim Adjuster's Signature
Date Processed:
NoYes
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Functional Area:
Print Form
Quantity
Lost
Estimated
Cost Per
Item
Approved?
(Completed by RM)
Replacement
Requested?
Item Lost/Damaged - Describe
(Include Make/Model/Serial #, suggested
vendor, etc.)
Continuation Sheet
Insurance Fund Claim Worksheet
Claim #:
Page 2 of 3Doc. #RSK-F001, Rev F 17 October 2018
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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Page 3 of 3Doc. #RSK-F001, Rev F 17 October 2018
Insurance Fund Claim Worksheet
Completion Instructions
Please make sure that all of the information is complete before sending form to Risk and Environmental
Services, Property Claims Unit.
1. All items claimed will be tracked by location and claim number. Make sure you include this information
on the worksheet.
2. List each item that was lost or damaged individually unless the item is generic in nature and can be
ordered in large quantities. (i.e. copy paper, text books, posters, manuals, etc.) Always list
electronics, technology equipment, and fixed assets individually and include serial numbers.
3. The estimated cost to replace the item can be found by searching the purchasing catalogs which are
available on the webpage http://erp.ccsd.net/
.
4. If the loss is due to burglary or vandalism, a $1,000 deductible* will apply to the total loss amount and
will be deducted from the total amount to be reimbursed to the site.
*If lost/damaged items were originally purchased with Federal Funds (verification required), no
deductible will apply to those specific items.
5. The Property Claims Unit will review the loss and make a determination of coverage.
6. The site will receive a memo explaining the coverage determination, whether or not a deductible will be
applied and the total amount to be reimbursed, along with a copy of the claim worksheet with any
notations from the claim examiner.
If possible, the expected reimbursement date will be provided at that time.
7. Any amount covered by the Property Claims Unit will be processed as an expense adjustment to the
site's Insurance Settlement account (Account 5889000000). Funds to that account should be used to
replace lost or damaged items.
8. The site will have 30 days from the date of reimbursement to submit supplemental costs, if
replacement costs exceed estimated costs.
IMPORTANT FACTS REGARDING CCSD PROPERTY LOSS CLAIMS:
• A Police Report MUST be filed for all Theft or Vandalism losses. Include a complete list of items involved
including serial numbers.
• Items MUST be listed on your site's inventory and/or fixed asset list prior to the loss.
• The claim must be filed and all necessary documentation completed within ninety (90) days of the
incident. (See CCSD Regulation 3612)
• The $1,000 deductible applies to each incident. If you are burglarized two days in a row, two separate
losses will be entered and a separate deductible will apply to each.
Please review the CCSD Property Loss Claim Process by visiting:
http://ccsd.net/departments/property-crime-and-liability/ccsd-property-loss
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Insurance Fund Claim Worksheet

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Completed 10 June 2021

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