INSURANCE CLAIM NON-THEFT

							                            INSURANCE CLAIM WORKSHEET
                                   DAMAGE TO       EQUIPMENT
                                                   WARDROBE
                                                   PROPS
                                                   SET DRESSING
                                                   LOCATION/PROPERTY

PRODUCTION

DATE OF OCCURRENCE                    TIME

WHAT WAS DAMAGED



LOCATION OF OCCURRENCE


HOW DID DAMAGE OCCUR




WITNESS                                        POSITION
PHONE#

DAMAGED ITEM(S)      PURCHASED FOR SHOW—PURCHASE PRICE $
                     RENTED FROM/OWNER
                       ADDRESS

                        PHONE #
                       CONTACT

                  RENTAL PRICE $                     PER   DAY
                                                     PER   WEEK
                                                     PER   MONTH
 VALUE OF DAMAGED ITEM(S) $
       ESTIMATE TO REPAIR $
  ATTACHMENTS



  SUBMITTED TO INSURANCE AGENCY ON
                          ATTENTION
                             CLAIM #
     INSURANCE COMPANY CLAIMS REP.


INSURANCE CLAIM WORKSHEET COMPLETED BY
DATE                               TITLE

 AMOUNT CREDITED TO AGGREGATE DEDUCTIBLE $                     DATE
REIMBURSEMENT CHECK PAID TO
                                 AMOUNT $                      DATE