Form Drm C-9 Property/casualty Loss Report
Download a blank fillable Form Drm C-9 Property/casualty Loss Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Drm C-9 Property/casualty Loss Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Fill in all applicable blanks
DRM #C-9 10/9/98
UNIVERSITY OF CALIFORNIA
PROPERTY/CASUALTY LOSS REPORT
Campus: ___________________Unit: __________________________________ Date: ______________________________
Potential fund Source/s:
[] BUS-1
[] BUS-9
[] BUS-28A/29A [] BUS-28B*
[] BUS-28C
Admin. Code: _________ [] BLDRS. RISK [] BUS-69 [] BUS-73
[] BUS-75 __AL __GL [] 3-D
SECTION 1. PROPERTY LOSS (University Property Only) [] INFORMATION ONLY
1. Date of Loss _________________ Time ________________ Date Reported ____________________________________
Location __________________________________________________________________________________________
2. Property Description _________________________________________________________________________________
Project Name ________________________________________________ Project No. _____________________________
Owner/Gen. Contr. __________________________________________________________________________________
Name
Address
Phone
2.1 Make/Model/Year _____________________________ U.C.# ________________________ License# _______________
No. of Vehicles _________________ No. of Injured Parties __________________ No. of witness________________
2.2 Property #______________________ Serial# __________________________ Estimated Value $ __________________
3. Cause of Loss/Damage _______________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
4. Title of Property: [] Regents [] State/Federal Govt. [] Other - Specify _______________________________________
If loss involves U.C. vehicle, check one: [] Central Garage
[] Assigned to Department
[] Departmentally Owned
[] Other
5. Driver Name ___________________________ License # ______________ Department __________________________
Fault:
[] U.C. Driver
[] Other Driver
[] Not determined (explain) _________________________
_________________________________________________________________________________________________
6. Action Requested:
[] Repair
[] Replacement
Estimated Cost $ _______________________________________
7. Department Name and Account #: ______________________________________________________________________
[] Check if Auxiliary Enterprise
8. Use of vehicle: [] Authorized [] Not Authorized (explain) _________________________________________________
9. Loss/Damage Reported by: _________________________________________________ Title ______________________
10. Police Authority to Whom Incident was Reported: ___________________________ Police Report # ________________
11. Documents Attached:
[] Photographs
[] Repair Invoice
[] Police Report
[] Diagrams
[] Salvage Statement [] Subrogation Results [] Other
12. Gross Loss $ ______________________ Deductible $ ________________________ Amt. to Fund $ ________________
13. [] Request Approved
[] Request Not Approved
[] Approval Require
[] Advance Funding Required
(attach supporting documentation)
14. Additional Comments: _______________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Submitted by:______________________________________________________________________________
Campus Risk Manager/Project Manager/Designee
Signature certifies that property qualifies for Coverage B.
Distribution: Original to Campus Risk Management Office - (Campus Risk Mgmt. to forward a copy to OPRM) 10/09/98 Rev.
Retention:
Risk Management - 5 years after settlement Other Copies - 1-2 years after settlement
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business