EQUIPMENT INSURANCE POLICY
PROPERTY LOSS NOTICE
Contact Names and Addresses
Contact Phone Numbers
Timothy R. Kellogg, Manager
(269) 387-4827
Business Services
(269) 387-3657 FAX
2016 Seibert Administration Bldg.
Timothy.Kellogg@wmich.edu
Western Michigan University
Kalamazoo, MI 49008-5222
Laura C. Vine, Risk Analyst
(269) 387-4825
Business Services
(269) 387-3657 FAX
2022 Seibert Administration Bldg.
Laura.Vine@wmich.edu
Western Michigan University
Kalamazoo, MI 49008-5222
Name of Person Reporting Loss ____________________________________________________
Department ____________________________________________________________________
Date of Loss ________________ Time of Loss ________________ A.M. ____ P.M. _____
Location of Loss ________________________________________________________________
Description of Loss ______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Loss Information
Type of Equipment
Serial Number
WMU Number
Value
______________
Total Loss ⇒ $
Was a Police Report done? Yes ___ No ___
If yes, write the report number ____________, or please attach a copy.
Fund and Cost Center to be reimbursed ______ - ________________
Equipment_Insurance_Loss_Notice.doc