Williamson County Government Risk Management Division Property Loss Notice

2. Williamson County School System
   Student Treatment Form
   
   Williamson County Risk Management

3. Claim #

   Risk Management Use Only

5. 1320 West Main Street, Suite 108
   Franklin, Tennessee 37064
   Telephone: (615) 790-5466 Fax: (615) 591-8516
   Email: wayne.franklin@williamsoncounty-tn.gov

7. Loss Information

8. Department/School*

9. Date of Loss/Time of Day *

11. Loss Location (incl. city/state)*

13. Authority Contacted:

14. Report #

16. Loss Details
    (Use separate sheet if necessary for complete explanation)

    (Use separate sheet if necessary for complete explanation)

18. (1) Type of Loss:

    1. Fire
    2. Theft
    3. Lightning

    1. Hail
    2. Flood
    3. Wind

19. Other

21. Description of Loss and/or Damage (Use separate sheet if necessary for complete explanation)

23. Make/Model, Serial/ID #, $ Estimate of Loss

25. (2) Type of Loss:

    1. Fire
    2. Theft
    3. Lightning

    1. Hail
    2. Flood
    3. Wind

26. Other

28. Description of Loss and/or Damage (Use separate sheet if necessary for complete explanation)

30. Make/Model, Serial/ID #, $ Estimate of Loss

32. (3) Type of Loss:

    1. Fire
    2. Theft
    3. Lightning

    1. Hail
    2. Flood
    3. Wind

33. Other

35. Description of Loss and/or Damage (Use separate sheet if necessary for complete explanation)

37. Make/Model, Serial/ID #, $ Estimate of Loss

39. (4) Type of Loss:

    1. Fire
    2. Theft
    3. Lightning

    1. Hail
    2. Flood
    3. Wind

40. Other

42. Description of Loss and/or Damage (Use separate sheet if necessary for complete explanation)

44. Make/Model, Serial/ID #, $ Estimate of Loss

46. Injured

47. Name

48. Address

50. City / State / Zipcode

52. Transported to Hospital:

    1. Yes
    2. No

53. Hospital Name:

54. Refused Treatment::

    1. Yes
    2. No

56. Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against Williamson County Government or its Excess Insurance Carrier, submits an application or files a claim report which contains a false or deceptive statement is guilty of insurance fraud and will be prosecuted to the fullest extent of the law.

58. Report Date:*

59. 20*

60. Reported By:*

Leave This Blank:


61. Submit

* indicates a required field