SOP_NUMBER: 404.03-att-1
TITLE: Insurance Notice of Loss Form
DIVISION: Administrative & Finance
TOPIC_AREA: 402-405 Policy-Administration and Finance
EFFECTIVE_DATE: 2020-07-01
WORD_COUNT: 277
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/173049
URL: https://gps.press/sop-data/404.03-att-1/

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

ATTACHMENTS:
  1. Insurance Notice of Loss Form
     URL: https://gps.press/sop-data/404.03-att-1/
  2. Sworn Proof of Loss Form
     URL: https://gps.press/sop-data/404.03-att-2/
  3. Lightning Affidavit
     URL: https://gps.press/sop-data/404.03-att-3/
  4. Property Transfer Form
     URL: https://gps.press/sop-data/404.03-att-4/

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FULL TEXT:
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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.