CHROMEBOOK Damage or Loss Report

1:1 Device Damage or Loss Report

This report may be completed by a parent or a school administrator in the presence of a parent
IMPORTANT: A device not enrolled in the school's device insurance program OR a device or any of its accessories that are lost, stolen, intentionally damaged or abused are the responsibility of the student and parent and the replacement cost must be paid to the school.

The 1:1 Handbook provided to students and parents can also be found on the school and corporation website.
Student Name*

First NameLast Name
Student Grade Level *

Kind.1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade
Parent Name*

First NameLast Name
Parent Phone Number*

Area CodePhone Number
Parent Email
Parent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date and time loss or damage occurred*

MonthDayYearHourMinutesAM/PM Option
Name of person completing and submitting this report (parent name or admin's name on behalf of parent)*

First NameLast Name
LOST, STOLEN or ABUSED (Select all that apply)*

None - Nothing lost, stolen or abusedCracked screen ($45)Carrying case ($20)Power cord (or part of cord/AC adapter) ($20)Entire device (includes power cord cost) ($225)
Device insurance will NOT cover lost, stolen or abused devices or accessories. Parents are responsible for 100% of costs when lost, stolen or abused.
ACCIDENTALLY DAMAGED or DESTROYED (Select all that apply)*

None - Items were lost, stolen or abused as indicated aboveCracked screen ($45, if not insured)Carrying case ($20, if not insured)Power cord/AC adapter ($20, if not insured)Entire device, includes power cord ($225, if not insured)Other
Did the parent DECLINE or ACCEPT insurance coverage when their child was assigned a device?*

DECLINEDACCEPTED
List any other details or related information not included above
School administration is required to verify if insurance coverage was accepted and paid. If insurance was accepted and paid, replacement or repair costs will be calculated and parents will be billed up to the appropriate deductible amount. If insurance was declined or not paid, parents will be billed the entire cost of repair or replacement.*

I (parent) understand the need for verification of insurance acceptance AND I also understand I will be responsible for the deductible amount or the entire costs if I chose not to accept insurance.
The E-Signature below indicates that all information provided on this form is understood, accurate and true (Parent signs below or admin if completing on behalf of parent)*
Should be Empty:

1:1 Device Damage or Loss Report