Fillable Property Loss Damage Report 10 2013 (California State University Channel Islands)

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Property Loss Damage Report 10 2013 (California State University Channel Islands)

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PROPERTY LOSS/DAMAGE REPORT
LOSS/DAMAGE DETAILS
C.I. Risk Management Rev 10/2013
DATE OF LOSS/DAMAGE TIME OF LOSS/DAMAGE
WHEN WAS THE L
OSS DISCOVER
ED?
BY WHOM?
PHYSICAL LOCAT
ION OR ADDRESS WHERE LOSS /DAMAGE OCCURRED
1
University
Drive
Camarillo CA
93012
CAUSE OF LOSS/DAMAGE (EX. FLOOD, FIRE, THEFT)
DESCR
IPTION OF PROPERTY LOST OR DAMAGED
DESCRIBE FULLY HOW
LOSS/DAMAGE OCCURRED
ENVIRONMENTAL IMPACT: ON LAND ON STATE B
UILDING OTHER NO IMPACT
SPECIFY ENVIR
ONMENTAL IMPACT (HAZ WASTE CONTAMINATION, RELEASE OF RADIATION)
EMERGENCY RESPONSE
FIRE
DEPT UNIVERSITY POLICE OTHER - SPECIFY:
REPORT NUMBER(s)
RESPONSIBLE THIRD PARTY
WAS THE LOSS/DAMAGE CAUSED BY A THIRD PARTY?
YES NO
INDIVIDUAL OR ENTITY NAME
ADDRESS
CONTACT TELEPHONE
PROPERTY LOSS/DAMAGE REPORT
LOSS/DAMAGE VALUATION
C.I. Risk Management Rev 10/2013
ESTIMATED VALUE OF PROPERTY LOST OR DAMAGED
DATE OF LAST
VALUATION OR APPRAISAL
ATTACH PURCHASE ORDERS OR INVOICES THAT INDICATE OWNERSHIP AND ORIGINAL PURCHASE PRICE
REMEDIATION, REPAIRS, REPLACEMENTS
REMEDIATION EFFORTS PROVIDED BY
UNIVERSITY PERSONNEL
OUTSIDE SERVICE
DESCRIPTION OF REMEDIATION ACTIONS AND REPAIRS
ESTIMATED TIME FOR REINHABITATION OR COMPLETION OF REPAIRS
ADDITIONAL DOCUMENTATION
PHOTOS
WORK ORDE
R(S)
CHANGE ORDER(S)
BILLS/INVOICES FOR REPAIRS AND OR/REPLACEMENTS
ESTIMATES FOR REPAIRS AND/OR REPLACEMENTS
INVOICES FOR ORIGINAL PROPERTY
OTHER DOCUMENTATION - SPECIFY:
REMARKS
REPORT PREPARED BY
DATE TELEPHONE
REPORT REVIEWED BY
DAT
E
TELEPHONE
NOTIFY RISK MANAGEMENT IMMEDIATELY WHEN PROPERTY LOSS OR DAMAGE IS EVIDENT.
SEND COPY OF REPORT TO RISK MANAGEMENT WITH 3 DAYS OF INCIDENT.
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Property Loss Damage Report 10 2013 (California State University Channel Islands)

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Completed 18 July 2020

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