What was the cause of the damage / loss?

If 'other' selected, describe type of damage / loss

Asset Type

Name of the Asset

Make

Model

Age of Equipment

Serial / VIN Number

Unit Number

Deed/Title Number

Amount and Currency of Cash

Describe the Damage to the Asset

Does the damaged property need to be repaired or replaced?

Yes No

Cost to Repair

Cost to Replace

Insurance Claim Number