State Property Fire Insurance Fund Loss Reporting Form

Submitted by cdecker3 on Thu, 10/10/2024 - 14:43

Please complete all fields. If available, provide a reporting date, attach photographs, repair invoices, repair quotes, and any other pertinent information to support and document your claim.

This form will be automatically submitted to Brian Hood. If you have any questions, please call 919-647-0064 or email Brian.Hood@ncdoi.gov.

Indicates required field

Department/University

Division Name

Date of Loss

Asset Name

Department/Division Number

Complex Number

Asset Number

Cause of Loss

Description of loss: What happened and how?

Reporting Person

Reporting Person Phone

Reporting Person Email

Contact Person

Contact Person Phone

Contact Person Email