Series 405.10P - Employee Property Claim

Employee name:                                                      Employee ID number:                         

Employee address:                                                                                                          

                             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 Comments:                                                                                                                                                                                                                                                                                                                                                 Code:                                                                                                               Human Resources signature                                             Date                            IF APPROVED, DATE FORWARDED TO FINANCE DEPARTMENT

 

Procedure/405.10P/2-23-18