Facilities Management Claim Form

Today's Date:
Date of Incident:
Time of Incident:
Date Facilities Management responded:
Location of incident (name of building, street address, etc):


Areas Affected:

Description of how the incident occurred: (example: If you indicate the overhead air handling unit froze, please provide an explanation of how it froze. What was the specific cause?)


Description of resulting damage sustained to Brown's property:

In order for resulting damage to be covered by insurance, there needs to be a specific identifiable cause of loss.

Service Number(s):

Estimated value:
$500 to $1,000
$1,000 to $4,999
$5,000 to $9,999
$10,000 to $24,999
$25,000 to $49,999
$50,000 to $99,999
Over $100,000

Status of work performed:

Contact person for this claim:
Contact phone number:

Any other comments?