Date of Occurrence by Tqurg9

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									                         TROUP COUNTY BOARD OF EDUCATION
                              INSURANCE CLAIM FORM
                                DAMAGE / LOSS OF USE

Date of Occurrence
Estimated Time of Occurrence
Facility
Exact Location
(i.e. room, building, etc.)
Cause of Damage




Please attach copies of any repair invoices or purchase orders including replacement parts
and/or systems. (If purchase orders or invoices are not available, make a best estimate.)

               Damaged Item                       Estimated      Location of Item for
                                                    Value        Insurance Inspection




Please report all incidents within 24 hours to:
Don Miller or Annette Duffee at ASC – 706-812-7900




                                                                            Revised 7/1/2008

								
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