Damage report for possible insurance claims processing

The following report is to be filled out and submitted to Risk Management for all damages, including but not limited to automobile accidents and damage to state-owned property, state-owned buildings (including water damage) or personal property.

If the loss was due to criminal activity (graffiti, theft, vandalism) or involves a vehicle accident or injury, please contact NAU Police Department dispatch FIRST at 928-523-3611 to file a police report and then follow up with filing this report.

Instructions:

Fill out all fields as completely as possible
Remember to include descriptive information
In the event of water damage to state facilities, refer to the “WATER DAMAGE RESTORATION GUIDELINE” procedures
Move from one field to the next by pressing the “TAB” key or use your mouse. DO NOT PRESS ENTER or this will close and submit the form.
A copy of the information you enter on this form will be sent to the email address you entered after you click “SUBMIT”
If you have any questions or concerns about this report or the process for damaged property, please contact Risk Management at (928) 523-2009
If necessary, a representative from Risk Management will contact you for additional information

NAU (State-owned) Property: When property of the state (Northern Arizona University) is damaged, this online Damage Report must be completed to initiate the claim process with State Risk for reimbursement.

Personal Property: If you feel your personal property was damaged or you were injured as a direct result of University responsibility, you may file this online damage report. Any additional forms you may need to file a claim against the State will be sent to your attention. For example, an NAU employee accidentally damages your electronic equipment while repairing your residence hall room.

For more information on coverage please review the information at the Risk Management website.

Check type of report
Choose Damage to STATE or PERSONAL property
Date & location information
Date occurred * Required
Time occurred * Required
Date reported * Required
Time reported * Required
City * Required
County
State * Required
Police report #
NAU campus location
Building name
Building #
Room #
Parking lot
Weather conditions during time of occurrence
Reporting party information
Name * Required
First Last
Department name
Occupation
Email * Required
Home phone #
Work phone #
Driver and state vehicle information
The following information must be provided for damage to state vehicles or damage to rental vehicles used for university business
Driver
Driver License #
State license issued
Expiration date
Home address
Street Address Address Line 2 City State ZIP Code
Driver's NAU department
Driver's occupation
NAU department address
Street Address Address Line 2 City State ZIP Code
Work phone #
Supervisor's name
Information on state vehicle damaged
Vehicle license #
Vehicle number
Vehicle year
Vehicle make
Vehicle model
Point of impact
ESTIMATED amount of loss?
Description of damaged property * Required
Describe damage to State vehicle or property: (example: windshield cracked by rock, or DELL OptiPlex GX1p Computer received water damage.)
Narrative
Include any additional remarks and actions taken.
State property losses that are not reported to Insurance and Claims Services in a timely manner may not be covered. State property losses not reported to State Risk Management within 90 days of the incident will not be covered.
Speedchart Number
To be used for reimbursement.
CAPTCHA

Damage report for possible insurance claims processing

Check type of report

Date & location information

NAU campus location

Reporting party information

Driver and state vehicle information

Information on state vehicle damaged

Narrative