State Risk Management Trust Fund
Notice of Property Loss
Agency's Name:
Certificate No:
Bureau, District or Institution Name:
Location/Address of Loss:
County:
Select County...
Alachua (11)
Baker (52)
Bay (23)
Bradford (45)
Brevard (19)
Broward (10)
Calhoun (58)
Charlotte (53)
Citrus (47)
Clay (48)
Collier (64)
Columbia (29)
Dade (01)
Desoto (34)
Dixie (54)
Duval (02)
Escambia (09)
Flagler (61)
Franklin (59)
Gadsden (21)
Gilchrist (55)
Glades (60)
Gulf (66)
Hamilton (56)
Hardee (30)
Hendry (49)
Hernando (40)
Highlands (27)
Hillsborough (03)
Holmes (51)
Indian River (32)
Jackson (25)
Jefferson (46)
Lafayette (62)
Lake (12)
Lee (18)
Leon (13)
Levy (39)
Liberty (67)
Madison (35)
Manatee (15)
Marion (14)
Martin (42)
Monroe (38)
Nassau (41)
Not in Florida (99)
Okaloosa (43)
Okeechobee (57)
Orange (07)
Osceola (26)
Palm Beach (06)
Pasco (28)
Pinellas (04)
Polk (05)
Putnam (22)
Santa Rosa (33)
Sarasota (16)
Seminole (17)
St. Johns (20)
St. Lucie (24)
Sumter (44)
Suwannee (31)
Taylor (37)
Union (63)
Volusia (08)
Wakulla (65)
Walton (36)
Washington (50)
Your Building No:
Date of Loss:
(MM/DD/YYYY)
Time of Loss:
:
AM
PM
Building Name:
NOTE: A SEPARATE FORM IS REQUIRED FOR EACH BUILDING.
Type of Loss:
Select Type of Loss...
Aircraft
All Other Losses
Civil Commotion
Disaster-Flood
Disaster-Lightning
Disaster-Windstorm
Explosion
Explosion-Boiler and Machinery
Fine Arts
Fire
Flood
Hail
Lightning
Lightning-Boiler and Machinery
Noc-Boiler and Machinery
Removal
Riot, Riot Attending Strike
Sinkhole
Smoke
Vehicle
Windstorm
Building - Estimate of Damages:
$
Contents - Estimate of Damages:
$
Detailed Description of Loss
Is any part of this loss covered by any other insurance?
Yes
No
If loss was fire related or caused damage to a fire arlarm system, was the State Fire Marshall's office notified?
Yes
No
N/A
Was loss previously reported to DFS Risk Management by telephone?
Yes
No
If Yes, Enter:
Caller's Name:
Date of Call:
(MM/DD/YYYY)
Phone:
DFS Contact:
Suncom:
Property Coordinator:
Name:
Title:
Phone Number:
Date:
Electronic Signature:
*
By placing your initials here, you are thereby signing this document with your signature.
Instructions:
Attachments in an email address will be permitted following successful submission of the form; a link willl be provided.
This
Notice of Property Loss
form will be used to report all claims within 90 days from the date of loss.
Report all claims with severe damage to the property fund immediately.
If you wish not to file this form electronically, complete this
Notice of Property Loss
in its entirety and mail to:
DEPARTMENT OF FINANCIAL SERVICES/RISK MANAGEMENT
BUREAU OF PROPERTY, FINANCIAL & RISK SERVICES
PROPERTY SECTION
200 EAST GAINES STREET
TALLAHASSEE, FL 32399-0337
CLAIM NUMBER
TRUST FUND USE
ONLY
COVERAGE CODE:
CAUSE:
LOCATION:
STRUCTURE CODE:
CARRIER CODE:
CERTIFICATE OF COVERAGE AMOUNT
BUILDING:
$
CONTENTS:
$
EXP:
BY:
RCVD/NOTIFIED DT:
electrelectronic version (DFS-DO-854)
(Revised 8/2009)
Rule 69H-1.003