ASU Claims Loss Report

ASU Claims Loss Report

The following loss report is to be filled out and submitted to Office of Risk Management for all damages, including but not limited to automobile accidents and damage to ASU-owned property, ASU-owned buildings (including water damage) or ASU personal property, including but not limited to office supplies, office furnishings, electronics, etc.

ASU's insurance does not cover the loss or damage of personal property of employees and students, and this form should not be used to submit claims of that nature.

Once the form is submitted, you will be contacted by ORM within 72 hours with the ASU and/or State Claim number assigned to this incident and the next steps.

If you have any questions before filling this form out please contact: askrisk@asu.edu

𝗣𝗟𝗘𝗔𝗦𝗘 𝗥𝗘𝗔𝗗 𝗕𝗘𝗙𝗢𝗥𝗘 𝗖𝗢𝗡𝗧𝗜𝗡𝗨𝗜𝗡𝗚

FACMAN DEPARTMENTS MUST SUBMIT THEIR CLAIM DIRECTLY TO: 𝗳𝗮𝗰𝗺𝗮𝗻𝗶𝗻𝘀𝘂𝗿𝗮𝗻𝗰𝗲@𝗲𝘅𝗰𝗵𝗮𝗻𝗴𝗲.𝗮𝘀𝘂.𝗲𝗱𝘂

FACMAN Insurance will then submit the claim using this form.

𝗡𝗢𝗧 𝗙𝗢𝗥 𝗣𝗘𝗥𝗦𝗢𝗡𝗔𝗟 𝗣𝗥𝗢𝗣𝗘𝗥𝗧𝗬 𝗨𝗦𝗘

This form should not be used for damage to personal non-ASU-owned property.

To notify ASU of a third-party loss, please submit an incident report here.

Submitting an incident report is only to notify ASU of the damage or loss so that we may contact you for more details, it is not an acceptance of liability or admittance of guilt by ASU, ABOR or the State of Arizona and it does not satisfy the Notice of Claim requirements of the State of Arizona (A.R.S. 12-821.01).

Any personal property claim submitted using this form will not be accepted.

Submitter information

Submitter email*

MUST ENTER A VALID ASU EMAIL ADDRESS

Use of a personal email address will prevent the submitter from receiving notification regarding this claim.

Do you want to be CC'd on email correspondence related to this claim?*

The department contact will automatically receive communication regarding this claim. If you would like to be included in any email communication, please select yes.

Yes

Is there anyone else who should be CC'd on email correspondence related to this claim?*

The department contact will automatically receive communication regarding this claim.

Select from the dropdown below. If you do not see the additional contact, enter their ASU email and press 'enter'.

Select or enter value

Section 1: Reporting requirements

ASU is insured by the State of Arizona, which requires that all claims must be submitted in a timely manner. The Loss Report and required documentation must be received within the timelines set forth below. Any claim reaching 90 days with no action or any claim submitted after 90 days will be denied.

For Property Loss:

1 day from discovery of loss for property damage expected to exceed $10,000.
10 days from discovery of loss for losses under $10,000.

For Auto Loss:

1 Day from discovery of loss for vehicle damage estimated at $5,000 or below.
10 Days from discovery of loss for vehicle damage estimated above $5,000.

Section 2: Document requirements

In order to properly asses the claim, the following must be submitted with the claim, where applicable:

This Loss Report.
Original Purchase Order/Receipts.*
Detailed Quote/Estimate.
Property Control/Serial Numbers.*
Pictures.
Police Report.

*content damage/theft

Section 3: Claimant information

Department name*

You can search for your department in the drop down menu.

IF YOU DO NOT SEE YOUR DEPARTMENT IN THE DROP DOWN, TYPE IN YOUR DEPARTMENT'S FULL OFFICAL NAME 𝗔𝗡𝗗 𝗣𝗥𝗘𝗦𝗦 '𝗘𝗡𝗧𝗘𝗥'.

Select or enter value

Department mail code

Department contact name*

Who should be contracted regarding this claim?

Department contact email*

MUST ENTER A VALID ASU EMAIL ADDRESS

Use of a personal email address will prevent the department contact from receiving notification regarding this claim.

Cost center*

Please enter the account information for reimbursement of this claim.

Program, gift, grant or project code*

Please enter the account information for reimbursement of this claim.

Section 4: Claim type

What type of damage are you submitting a claim for?

Property damage. Damage to ASU’s buildings, walls, doors, floors, windows, parking structure, gates, etc.

Content damage. Damages to ASU owned electronics, office furnishings, or office supplies.

Auto damage. Physical damage to ASU owned, rented, or leased Vehicles or Carts.

Windshield damage. Use only if you are submitting a claim where there is only windshield damage.

If you have an additional loss type, please submit a new loss report.

Example: A building water leak that results in damage to office supplies/electronics. One loss report should be submitted for Property Damage for the building damage and another loss report should be submitted for Content Damage for the office supply/electronic damage.

Select the claim type:*

Property Damage

Contents Damage

Auto Damage

Windshield Damage

Is this incident related to a claim that has already been submitted/opened or another incident that will be submitted?*

Yes

Please provide the Claim# for the submitted/opened claim this incident is related to:*

If you have not received the ASU claim number from Risk Management yet please attach a copy of the email confirmation you received to this entry.

Section 5: Critical information

Do any of the following situations apply to this claim?*

Please select 'Yes' or 'None Apply'. If you select Yes, please check which situations apply below.

Yes

None apply

ASU Employee physical injury

Please explain the ASU employee physical injury

3rd party physical injury

Please explain the 3rd party physical injury

Student/Faculty displacement

Please explain the student/faculty displacement

Please explain theft/vandalism

Section 6: Loss/Incident information

Date of loss/incident*

Location of incident*

Please select from the list of ASU buildings and parking structures listed below. If this incident did not occur in any of the locations listed, please select "Other Location".

You can begin typing the building name, address or code and the location should populate.

Select from the list below

Error: you selected "---" please select a building or other location.

Please detail the other location*

For property loss, include name of building/rooms. For auto loss, include city, state, cross streets, highway, or mile markers.

Describe in detail how the damage/loss occurred*

Has a Remediation Company been assigned?*

Yes

Remediation Company name and contact information:*

Is a contractor or 3rd party involved with this claim?*

Yes

Contractor/3rd party name and contact information:*

Estimated total amount of loss*

An estimate of the damages is important to determine whether the claim needs to be submitted to the State of assistance. Please provide an appraisal, it does not have to be the final quoted amount.

PLEASE ONLY ENTER AN ESTIMATED DOLLAR AMOUNT (EX. $1,000)

Vehicle was involved with:

Select or enter value

Section 7: ASU Vehicle information

Vehicle Type*

ASU Owned Vehicle/Cart

ASU Leased Vehicle/Cart

Rented Vehicle/Cart

Did you rent this vehicle using an ASU/State contract?*

ASU's has a negotiated contract with Enterprise, and the State has a contract with Hertz. Were either of these contracts used to rent this vehicle?

Yes

Rental company name*

Please be sure to attach a copy of the rental agreement to this loss report.

ASU issued vehicle #*

ASU vehicle year, make and model*

Do not enter "Unknown". If you are unsure of the vehicle details please check the vehicle registration.

What is the point of impact on the vehicle?

Was the vehicle removed from the scene of the incident?*

Yes

Where was the vehicle removed to?

Who was the vehicle removed by?

Section 8: ASU Driver information

Was the vehicle being driven at the time of damage?*

Yes

Who was driving?*

Select or enter value

ASU Employee/Affiliate ID#*

Driver contact number

What state was the license issued?

Driver's license expiration date

Section 9: 3rd Party Driver & Vehicle Information

Did this incident involve a 3rd party?*

Yes

3rd party first and last name*

3rd party contact number*

3rd party contact email

3rd party vehicle (year, make, model)*

3rd party license plate#*

What is the point of impact on the vehicle

Was the vehicle removed from the scene of the incident?

Select or enter value

Where was the vehicle removed to?

Who was the vehicle removed by?

Who is the 3rd party's insurance carrier?*

Section 10: Witnesses

Were there witnesses to this incident?

Yes

Witness #1: first and last name

Witness #1: contact number

Witness #1: contact email

Witness #2: first and last name

Witness #2: contact number

Witness #2: contact email

Witness #3: first and last name

Witness #3: contact number

Witness #3: contact email

Please Attach Required Documents*

Original Purchase Order/Receipts.**
Detailed Quote/Estimate.
Property Control/Serial Numbers.**
Pictures (jpeg or pdf photos only. System cannot accept HEIC)
Police Report.

**required for content damage/theft.

Drag and drop files here or

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