DCF 86-3
(rev. 2/2013)
State of New Jersey
DEPARTMENT OF CHILDREN AND FAMILIES
EMPLOYEE CLAIM FOR LOSS OR DAMAGE TO PERSONAL PROPERTY
1.
Name of Claimant:
2.
Title or position:
3.
Where employed (Division, if applicable; office/unit/institution; address):
4.
Full description of item lost or damaged:
5.
Name and address of store where lost or damaged item was purchased:
6.
Date of Purchase:
7.
Purchase price (attach copy of receipt, if available): $
8.
Claimant’s estimate of present value of item: $
9.
Date of incident:
10.
Description of incident resulting in loss or damage:
11.
Name(s) of person(s) willing to sign below as witness(es):
12.
Full description of nature and extent of damage:
13.
If repairs are required, indicate estimated or actual repair cost in following space and attach estimate
or receipt: $
14.
Is the loss/damage covered by any insurance (e.g., comprehensive auto, homeowner’s, etc.) held by
claimant on any individual or group basis? Yes
No
If no, go on to # 15
14a. Type of applicable first-party insurance:
14b
Has compensation been sought from applicable first-party sources? Yes
No
Amount recovered: $
15.
Amount suggested by claimant as a reasonable settlement: $
Claim certified by:
___________________________________
Incident witnessed by:
___________________________________
Claimant (signature)
___________________________________
Claimant’s Supervisor
____________________________________
Supervisor’s Signature
____________________________________