Download OHSU Report of Lost/Damage/Stolen Property

OHSU Report of Lost/Damage/Stolen Property
For Internal Use Only
Today’s Date:
Department
OHSU Property damage/loss/theft
Damage/loss/theft to property of others
Department ______________________________________
Mail Code: _____________________
Person completing form _____________________________
Daytime Phone: _________________
Date of Loss:
Hour
A.M
P.M.
Location: Building Name:_________________________ Floor/Rm#__________________
Incident Details
Exact Location and circumstances of Loss:
Responsible Party Name and Address:
OHSU Employee
Public Safety Report:
No
Yes
Other
Case #
Vehicle; Make, Model, & Plate Number_____________________________________________________
Specific Property Damaged/Lost/Stolen:
If applicable, where can property be inspected?
________________________________________________________
Complete all the cost and value blanks.
A. Item’s value shown on inventory:
B. Cost to Repair:
C. Cost to Replace:
D. Loss (lesser of B or C):
$ _____________
$ _____________
$ _____________
$ _____________
Lower of price agreement or 3 vendor estimates or bids.
Cost to buy a new item of same/like kind of damaged item.
How will loss payments be used? _____ Repair or replace the item ______ For this alternative use
Witnesses
Name and Address
Signature
Title
Return the completed form and any other information to Risk Management – Mail Code L328
OHSU REPORT OF LOST / DAMAGED /STOLEN PROPERTY
For Internal Use Only
Page 2
INSTRUCTIONS: This form is to be used only by OHSU departments and employees. Use this report to
request coverage from Risk Management under the OHSU self-insurance plan. This form must be filled out
COMPLETELY. If a line does not apply to your loss, respond with "NA" or "NONE".
Liability claims, as well as potential liability claims, should be reported to us immediately. All property claims
MUST be reported to Risk Management as soon as possible. Property claims filed after 90 days may be
denied because of late filing.
Risk’s policy is to make the department “whole”. We will repair or replace the damaged / lost / stolen
equipment with like quality. Any enhancements are at the departments cost.
PROPERTY CLAIMS: Immediate reporting is critical. Please attach:
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Copies of applicable letters, police reports, orders, rules, invoices, original photographs and any other
materials relating to the claim.
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a copy of the original purchase order / receipt
the asset number or ITG assigned number
If the laptop is s stolen or lost, copy Ron Marcum in Corporate Compliance on the report.
Witnesses and involved parties’ names, addresses and phone numbers.
The lawsuit, if you were served. Write on the summons when it was received in your office and by
whom. Call us immediately. Send Risk a copy of the summons and complaint.
LIABILITY CLAIMS: Immediate reporting is critical. There is often a person who is injured or has damaged
property who is expecting us to contact them. DO NOT DELAY. Please attach:
 Copies of applicable letters, police reports, orders, rules, Motor Vehicle Division’s Traffic Accident and
Insurance Report, original photographs and any other materials relating to the claim.
 Witnesses and involved parties’ names, addresses and phone numbers.
 The lawsuit, if you were served. Write on the summons when it was received in your office and by
whom. Call us immediately. Send Risk a copy of the summons and complaint.
FOR ALL CLAIMS: In all cases be sure to:
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Preserve all physical evidence. If possible take pictures of the scene.
Give us the name and phone number of your contact person for further information.
Inform us of the best time and method to get in touch with you.
Do not delay your report. If documents or information are missing, complete the report form and submit
it with what you have. Follow up with the missing information.
If you have any questions on coverage, documentation or actions you should take, call us at once.
WHAT’S NEXT: Risk will investigate and resolve the claim. Do not discuss the claim with anyone except us
or our designated representative. Do not take any actions to resolve a claim without talking to us. If there is an
urgent matter, contact us immediately.
Risk will work with your department to establish the value of the loss. The current process for reimbursement
is to have the department purchase the replacement equipment or pay for the repair for the equipment using
their normal department Fund-Org. Fax Risk a copy of the GL after the transaction has posted. Risk will
process a Journal Entry (JE) reimbursing you for this expense. We will arrange the sale of destroyed vehicles
and other salvageable property.
Contact Risk Management with any questions of concerns – 503-494-7189
Return the completed form and any other information to Risk Management – Mail Code L328