Uninsured Property Loss: List UNINSURED property destroyed, damaged or stolen from this incident. We must prove the “fair market value” or “as is” value of each item lost. Replacement value is not the same as fair market value. You should, if possible, document the fair market value of the item(s) that were damaged, destroyed or stolen.

Insurance Information: If any damaged/stolen property were/are covered by an insurance provider please fill out the information below:

Costs/Insurance Information: If any of the items listed above were/are covered by an insurance provider please fill out the information below:

If the victim missed work or incurred child care expenses as a result of the crime, please provide the following information requested below. Additionally, please forward my office any documentation for the listed items.