PHILFLEX ®

PHILIPS WIRE & CABLE CO.

Property/ Product Loss/ Damage Report Form Control no. ________________

Date of Incident:
Location of Incident:
Time:

Type of Loss:
o Accident o Vandalism o Others
o Fire o Theft
Please specify:

Description of the Property Damage:

Description of how the incident occurred:

EMPLOYEE FILING THIS REPORT

Name: Position:
Signature: Date

FOR ADMINISTRATION USE ONLY

Approximate Cost of Repairs: ______________________________________________

Approximate Cost of Replacement: ______________________________________________

Signature: ___________________________ Date: _____________________________

HRDLC-PLDRF1015-02