Property Damage Report Form - Brown County

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Brown County
Property Damage Report Form
Reported by: _______________________ Dept.: ____________________ Date: _______________
Date of Incident: ________________Time of Incident ________a.m. ________ p.m.
Location of Incident: _______________________________________________________________
Cause of Loss
Fire and/or smoke
Roof Leak
Theft or vandalism
Lightning
Pipe Leakage
Transit/during shipment
Wind
Backup of sewer or drains
Vehicle
Flood
Underground seepage
Utility Interruption
Explosion
Escaping fluids
Electrical failure or
disturbance
Earth movement, settling or
Mechanical breakdown
Spoilage
cracking
Hazardous materials
Computer virus or cyber
Other (provide
release/contamination
attack/threat
explanation below)
Other/Notes: ________________________________________________________________________________
Police Dept. Notified? _______ Yes ________ No Fire Dept.? __________ Yes _________ No
Please provide a brief description of the type of damage:
________ Damage to Property _______________________________________________________
________ Other (describe) __________________________________________________________
Name of Party __________________________________________ Phone _____________________
Address (include complete address, with street address, city, state and zip)
_____________________________________________________________________________________
Driver’s License No. ___________________________________________________
Briefly Describe What Happened: ____________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Estimated Dollar Value of the Loss _________________________________________
(Approximate value to repair and/or replace damaged property with like kind and quality.)

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