NSHE Property Loss Report Form

Date of Incident (required)

Time of Incident (required)

Street Address Where Loss Occurred (required)

State (required)
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code (required)

Estimated Value of Loss (In $USD) (required)

Provide a detailed description of what happened and what was damaged/lost.
(required)

Please include photos, witness statements, police reports, and any other supporting documents you may have.

(Please note: Documents must not exceed 5MB in size)

Name of Contact Person (required)

Email (required)

Phone (required)

Fax

Department (required)

PG Number