LOSS OR DAMAGE REPORT

Department : Date:
Completed by:
Verified by:
Incident Number:

Reason of Loss Type of Loss

□ Theft □ Vehicular □ Property Damage □ Business

□ Vandalism □ Accidental Damage □ Inventory □ Other :
□ Burglary □ Unknown □ Money/Cash
□ Fire/Arson □ Employee
Incident Information
Date of loss: Time of Loss:
Date Reported: Time Reported:
Police Notified: Report Number:
Police Contact: Phone Number:

Incident Description:

Comments:

Completed by Signature:
Verified by Signature: