** This is a Required Field
Denver RELOCATION PROPERTY LOSS NOTICE
Please submit online by clicking the button below, or fax to:
Mollie Anchustegui
(303) 315-8583
 TODAY'S DATE **
MOVE DATE **
DATE AND TIME OF OCCURRENCE **
Date:Time:AM/PM:
INSURED/DEPARTMENT AND ADDRESS
MOVE COORDINATOR **
DEPARTMENT NAME **
 DEPARTMENT CODE
 DEPARTMENT CONTACT **
 DEPARTMENT PHONE **
WHERE TO CONTACT
 WHEN TO CONTACT
 2nd BUSINESS PHONE
LOSS
LOCATION OF LOSS **
 TYPE OF LOSS **
Missing Damaged
DESCRIPTION OF OCCURRENCE **

  • FOR MISSING ITEMS, PLEASE INCLUDE A DESCRIPTION OF THE ITEM, COLOR OF THE LABEL, HOW IT WAS LABELED (LOCATION, ETC.) AND WHERE THE ITEM CAME FROM (ROOM #, BUILDING, ETC.)
  • FOR DAMAGED ITEMS, PLEASE INCLUDE A DESCRIPTION OF THE EQUIPMENT AND HOW IT WAS PACKED OR MOVED. PLEASE KEEP ALL PACKING MATERIAL FOR THE INSURANCE COMPANY.
  • IF ANY CHEMICALS ARE MISSING OR BROKEN DURING THE MOVE, PLEASE CONTACT HEALTH & SAFETY IMMEDIATELY AT (303) 315-5890.
    • REPORTED BY
    REPORTER'S NAME **
    		 DATE AND TIME REPORTED **
    		 REPORTED TO **
    ** This is a Required Field
    It is unlawful to knowingly provide false or misleading information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages.