STATE OF COLORADO LOSS NOTICE
THIS FORM IS USED TO REPORT
STATE-OWNED PROPERTY, BOILER AND MACHINERY, BOND AND CRIME LOSSES

SEND (e-mail, mail, or fax) TO:
State Office of Risk management
1313 Sherman Street, Room 114
Denver, CO 80203
303-866-4971; fax 303-894-2409
E-mail: Nicholas.witkowski@state.co.us

AS OF JUNE 7, 2010, THE PER OCCURRENCE PROPERTY LOSS DEDUCTIBLE HAS INCREASED FROM
$1,000 TO $5,000.

THIS FORM IS NOT TO BE USED FOR REPORTING LIABILITY CLAIMS

IMMEDIATELY UPON DISCOVERY of the state loss, this notice must be sent to the State Office of Risk
Management. The State Office of Risk Management will advise the insurance broker, who will notify the
insurance carrier and assign an adjuster. State agencies should take immediate steps to mitigate the
loss, maintain records to support the claim and must submit invoices or purchase orders or other
documents to the adjuster in a timely manner. Appraisals and estimates must be clearly itemized. The
adjuster will contact the designated agency contact person as soon as possible to discuss appropriate
action on the claim. Some losses may involve investigation by more than one insurance carrier, and
adjustment may require coordination of coverage.

FAILURE TO FILE A TIMELY REPORT OR TO PROVIDE THE ADJUSTER WITH FULL DOCUMENTATION MAY
DELAY OR DIMINISH THE LOSS REIMBURSEMENT.

Contact The State Office of Risk Management at 303-866-4971 with any questions.

LOSS DATE:

ESTIMATED LOSS VALUE:

STATE DEPTARTMENT:
Higher Education

STATE DIVISION:
Colorado School of Mines

CAUSE OF LOSS:
Choose an item

DID YOU APPLY FOR EMERGENCY FUNDING? Choose an item


CONTACT NAME (first/last):

Natalie

Martinez

POSITION:

Procurement and Risk Manager

PHONE:


303.273.3569
FAX:


303.273.3971


E-MAIL:
nmartine@mines.edu

STREET ADDRESS:
1500 Illinois Street

CITY:
Golden

STATE: CO

ZIP: 80401


PLEASE DESCRIBE IN DETAIL WHAT HAPPENED:







PLEASE DESCRIBE IN DETAIL WHAT ITEM(S) WAS LOST OR DAMAGED:






LOSS LOCATION:



POLICE OR FIRE AGENCY:
Golden Fire Department