State Risk Management Trust Fund
Notice of Property Loss

Agency's Name: Certificate No:
Bureau, District or Institution Name:
Location/Address of Loss: County:
Your Building No: Date of Loss:  (MM/DD/YYYY) Time of Loss: :  
Building Name:

NOTE: A SEPARATE FORM IS REQUIRED FOR EACH BUILDING.

Type of Loss:
Building - Estimate of Damages: $
Contents - Estimate of Damages: $

Detailed Description of Loss

Is any part of this loss covered by any other insurance?
If loss was fire related or caused damage to a fire arlarm system, was the State Fire Marshall's office notified?
Was loss previously reported to DFS Risk Management by telephone?

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:
  


electronic version (DFS-DO-854)

(Revised 11/2005)