Attachment C

Please fill out this claim form and submit it immediately to your school administrative office.

Please refer to the declaration page for coverage information. Coverage is not afforded where

any person has knowingly concealed or misrepresented any material fact or circumstance

concerning this protection plan.

Employee/Student Name:________________________________________________________

Address:_____________________________________________________________________

Main Phone: _________________________________________________________________

Describe Damages:

____________________________________________________________________________

____________________________________________________________________________

Describe, in detail, the circumstances of your incident:

____________________________________________________________________________

____________________________________________________________________________

The above statement is true and correct to the best of my knowledge.

Name: _______________________ _______________________________________

Printed Signature Date

Northwest Community Schools Technology Handbook 2020-2021 