NSHE Property Loss Report Form

Use this form to report theft, damage, or loss to NSHE property that exceeds the $2000 NSHE deductible.

For NSHE vehicle theft or damage, use the Vehicle Accident Report Form.
Any theft or loss below the $2000 deductible will be paid for by the department.
Risk Management and Safety will assist with any potential third-party recovery for losses.

Name:

Telephone Number:

Email:

Department:

Budget Account (PG Number) for Reimbursement:

Date of Incident:

Time of Incident:

Location of Incident:

Additional Location Information:

Were the police contacted?

Police Report Number:

Was the fire department contacted?

Fire Report Number:

Provide a Detailed Account of the Incident, Including Approximate Time, Item Location Prior to Damage or Theft, and Description of Item (Make, Model, and Color):

Upload Relevant Files (Max 10 files): Include any supporting documents such as photos, receipts, invoices, workday proof of purchase, police and fire reports.

I verify that the information submitted on this form is true and correct to the best of my knowledge. By typing my name below, an electronic signature will be created. My electronic signature will be treated in all respects as having the same force and effect as an original (wet) signature. By selecting the submit button, I agree with the aforementioned statement.

Full Name: