PROPERTY LOSS REPORT EXHIBIT

FORM INSTRUCTIONS

1. Department/College - Enter the name of the department or college where property loss occurred
2. Date of Loss - Select the date of loss from the drop-down calendar
3. Time of Loss - Enter the time of day the loss was identified
4. Contact Person - Enter the name of the contact person
5. Contact Phone - Enter the telephone number, including the area code, of the contact person
6. Contact Email - Enter the PSU email address of the contact person
7. Description of Incident - Provide a detailed description of the incident
8. Nature of Loss - Select the nature of the loss from the drop-down list. Options include water, fire, storm, electrical surge, robbery/theft, or other
9. Other - If other selected in previous field, provide the nature of the loss
10. Police Services - Check this box if Police Services were notified
11. Incident # - If Police Services were notified, enter the incident number
12. EH&S - Check this box if Environmental Health & Safety were notified
13. EH&S Name - If Environmental Health & Safety were notified, indicate the name of the individual receiving the report
14. OPP - Check this box if the Office of Physical Plant was notified
15. Work Order # - If OPP was notified, enter the work order number
16. OPP Name - If OPP was notified, indicate the name of the individual receiving the report
17. Building - Enter the name of the building where the incident occurred
18. Floor(s) - Enter the floor or floors on which the incident occurred
19. Rooms/Offices - Enter the room number or the name of the office in which the incident occurred
20. Address - Enter the complete mailing address of the building
21. 3rd Party Name - Enter the name of the individual or company causing the damage
22. 3rd Party Phone - Enter the telephone number, including the area code, of the 3rd party causing the damage
23. 3rd Party Address - Enter the complete mailing address of the 3rd party causing the damage
24. 3rd Party Email - Enter the email address of the 3rd party
25. 3rd Party Insurance Carrier - Enter the name of the 3rd party's insurance carrier
26. 3rd Party Policy # - Enter the insurance policy number of the 3rd party
27. Submitter Name - Enter the name of the individual submitting the Property Loss Report
28. Signature - The individual submitting the report must provide either a hand-written signature or provide their digital ID
29. Submitter Phone # - Enter the phone number, including the area code, of the individual submitting the Property Loss Report
30. Submitter Email - Enter the PSU email address of the individual submitting the Property Loss Report