Fillable PropertyLossIncidentReport - Document1

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PropertyLossIncidentReport - Document1

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WINTHROP UNIVERSITY PROPERTY LOSS/INCIDENT REPORT
Date of Loss: ________________________ Department: ___________________
Loss Location (provide complete address if off-campus): _________________________
Who was notified: Police: _________________ Public Safety: __________________
Was the Loss Related to Construction __________ Contract Work: ___________
If so, please provide Name of Project and Job Number: __________________________
Was this a Special Event if so please list: ______________________________________
Description of Loss/Incident, Extent of Damage, and Action Taken/Status of Repairs:
(Attach all supporting statements such as official reports, photographs if available or
other information for this report)
________________________________________________________________________
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INJURY INFORMATION:
Type and Extent of Injury Known:____________________________________________
Name of Injured Party: _____________________________________________________
Address: ________________________________________________________________
City/State/Zip: ___________________________________________________________
Telephone: ______________________________________________________________
Name and Address of Attorney: _____________________________________________
_______________________________________________________________________
If A Third Party Is Responsible:
Name of Person Responsible for Loss: ________________________________________
Address: ________________________________________________________________
City: __________________________State: ______________ Zip Code: _____________
If the responsible party is a Student, please check here: _________
If Property Was Leased/Borrowed:
Owner/Lessor Name: ______________________________________________________
Address: ________________________________________________________________
Telephone: ______________
Contact Person: ____________________________ Telephone: ______________
Department : ______________________________
WITNESSES:
Name: ___________________________________ Telephone: ____________________
Address: _________________________________ City/State/Zip: _________________
Name: ___________________________________ Telephone: ____________________
Address: _________________________________ City/State/Zip: _________________
REPORTED BY: __________________________ DATE: _______________________
CONTACT PERSON: ______________________ TELEPHONE: _________________
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PropertyLossIncidentReport - Document1

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Completed 11 March 2020

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