SOP 404.03-att-1: Insurance Notice of Loss Form

Division:
Administrative & Finance
Effective Date:
July 1, 2020
Topic Area:
402-405 Policy-Administration and Finance
PowerDMS:
View on PowerDMS
Length:
277 words

Summary

This is the official form used by Georgia Department of Corrections agencies to report insurable property losses to the Department of Administrative Services (DOAS) Risk Management Services. The form must be completed and faxed within 48 hours of discovering a loss and includes sections for documenting the type of loss, location, vehicle information (if applicable), cause of damage, and estimated loss amount. Agencies must also provide supporting documentation within 120 days to finalize claims for reimbursement.

Key Topics

  • insurance claim
  • property loss
  • notice of loss form
  • risk management
  • building contents
  • vehicle damage
  • all risk coverage
  • loss reporting
  • DOAS claim number
  • sworn proof of loss
  • agency insurance coordinator

Full Text

SOP 404.03
Attachment 1

7/1/20

State of Georgia Department of Administrative Services Risk Management Services

# NOTICE OF LOSS FORM

IMPORTANT: INSURABLE PROPERTY LOSSESS MUST BE REPORTED ON THIS FORM WITHIN 48
HOURS OF DISCOVERY OF THE LOSS BY THE INSURED AGENCY.
_Fax this form to: 478-992-6363_

PROVIDE THE FOLLOWING INFORMATION:

TYPE OF LOSS: (__) Building/Contents (__) All Risk (__) Vehicle Damage

Date of loss: _____________ Time of loss: _____AM/PM

Loss location: ___________________________________________ COUNTY__________

Your Agency: ____________________________ Department: _________________________________

Your Agency Ref. #: ___________ Agency Contact & Phone Number: __________________________

About Insured Vehicle: Year: __________ Make: __________________ Model: ___________________

Vehicle Identification number (VIN): ____________________________ DOAS ID#: ______________

Cause of Loss (Insured Peril): ____________________________________________________________

Type of Damages: ______________________________________________________________________

Loss Description (REQUIRED): __________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________
IF MORE SPACE IS NEDDED ATTACH A 2ND PAGE)

LOSS CONTROL MEASURES TAKEN TO REDUCE/PREVENT FUTURE LOSSES: ___________
______________________________________________________________________________________

ESTIMATED LOSS AMOUNT: ______________________

- An acknowledgement letter will be sent to the risk manager with the assigned DOAS claim number that must be included on the
Sworn Proof of Loss form and any other claim related correspondence

The DOAS retains the right to assign an outside adjuster to investigate the loss on its behalf. The Sworn Proof of Loss Form with
DOAS claim number, copies of original invoices for property, bills for material and labor and evidence of payment (check or approved
purchase order) for replaced or repaired items must be provided to finalize a claim with in 120 days. The required documents
substantiate reimbursement of damages for a claim. The DOAS will process the claim and send a reimbursement check for all perils
covered under the policy.

_____________________________________ ________________________
AGENCY INSURANCE COORDINATOR DATE
______________________________ _______________________
PHONE NUMBER FAX NUMBER

Retention Schedule: Upon completion, this form shall become part of the Purchase Order package and
retained for five (5) years. It shall then be destroyed.

Attachments (4)

  1. Insurance Notice of Loss Form (277 words)
  2. Sworn Proof of Loss Form (349 words)
  3. Lightning Affidavit (151 words)
  4. Property Transfer Form (76 words)
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