Series 405.10P - Employee Property Claim
Adopted: February 2018
Employee name: Employee ID number:
address city state zip
Description of Property Damaged or Destroyed (attach photo if possible):
Estimated repair or replacement cost (receipt required prior to reimbursement):
Date of incident:
Description of incident:
Witnesses, if any?
I verify that the above information is true and correct and the claimed property is not covered by workers compensation or any other insurance. I have reviewed District 196 Regulation 405.10AR, Employee Property Claim and make this claim pursuant to the regulation.
Employee signature Date
Supervisor’s signature Date
Principal/Administrator signature Date
Human Resources Department Claim Review: □Approved □Disapproved
Human Resources signature Date
IF APPROVED, DATE FORWARDED TO FINANCE DEPARTMENT