Office Leaseholder Theft Loss Notice

1. Leaseholder Information

Full Name Company/Organization Office Address Contact Number Email Address

2. Incident Details

Date of Theft Time of Theft Location within Office Premises Brief Description of the Incident Items Stolen (List and describe each item) Estimated Value of Loss

3. Additional Information

Any witnesses? If yes, provide details Police Report Filed? (Yes/No and Report Number if available) Other Relevant Information

4. Declaration

Name of Person Submitting Notice Date Signature (type your name)