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2. 
4. Property/Equipment Loss Report Form
6. Date of Incident
   Date of Incident
7. Department/Agency
9. Name and Address of Person Filing Report
11. First Name
12. Middle Name
13. Last Name
15. Address
16. City
17. State
18. Zip Code
20. Location of Incident
21. Facility Injured Person Treated At
22. Date of Treatment
    Date of Treatment
24. Please Describe Incident
26. Estimate
27. Picture(s)
28. Equipment Returned?

    1. Yes
    2. No
29. Injury Insurance Claim Instructions
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31. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that: 

    • 1) your submission will not be signed in the sense of a traditional paper document;
    • 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature; and 
    • 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
33. Electronic Signature*
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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

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