ONLINE LOSS LISTING FORM

You may download a paper copy of this form if preferred.

Step 1: Fill out the case information you want to report losses for.

Case Number (12 Digits)

Victim's First Name (e.g. John)

Victim's Last Name (e.g. Doe)

Telephone Number (Format: ###-###-####)

Step 2: Add items and property below including make/model and serial numbers if known.

INSTRUCTIONS: List type of item, give make, model, and serial number, or physical description of the item; i.e., size, color, material, design, men's, women's.

JEWELRY: identify any type of metal (yellow gold, silver, platinum, etc). Indicate the type, size, weight, shape, and color of stones, etc.
FURS: Indicate type of fur, color, size, style, maker or other identification.
GUNS: give manufacturer, model, serial number, caliber, length of barrel, color of weapon & stock, etc.
CURRENCY: Indicate whether U.S. or FOREIGN notes and furnish denominations, etc.
STEREO-TV: Indicate make, model, serial number, color, black & white, size of screen, etc.
BANK CHECKS/TRAVELER CHECKS/CREDIT CARDS: Identify by name or issuer or bank, give serial numbers or account numbers.
NOTE: Items should be reported at estimated fair market value, subject to depreciation. Values indicated should not include retail replacement cost.

Item 1

Name of Item

Make / Model

Serial #

Value

Description Maximum 250 characters.

Step 3: Add attachments such as pictures and documents below. Limit: 10 distinct attachments, 20 MB maximum in total.

File to Add

Associated Item

Brief Description of the Attachment

Step 4: Electronically Sign and Submit

Note: FLORIDA STATUTE 837.06 FALSE OFFICIAL STATEMENTS: Whoever knowingly makes a false statement in writing with intent to mislead a public servant in the performance of his official duty shall be guilty of a MISDEMEANOR of the 2nd degree.

Name of Person Filling Out this Form:

I agree that the information in this electronic document is fully accurate to the best of my knowledge.