State Risk Management Trust Fund
Statement - Lightning Losses


Certificate #: (#-###-##) Building #:
Building Name:
Date of Loss: (MM/DD/YYYY) Time of Loss: :  

List all equipment damaged by this strike:
Was a lightning protection system or arrestor system in place?
If yes, was it damaged?
State Physical Evidence or Reasons Why Loss Appeared to be Result of Lightning:
Attach Photo of Physical Evidence Showing Lightning Damage:
Uploaded Photos of Physical Evidence Showing Lightning Damage:
Note: The photo that you may attach must either be in GIF or JPEG format. Additional Attachments will be permitted following successful submission of the form. A link will be provided.
Approximate Date of Previous Lightning Losses: (MM/DD/YYYY)

It is my firm conviction that this loss was a result of lightning and was not occassioned by low voltage, a power surge, a mechanical breakdown or because of a defect in the equipment.
Repairman or Licensed Electrician Name:

Name: Title:
Phone Number: Date:

Electronic Signature:
* By placing your initials here, you are thereby signing this document with your signature.

electronic version (DFS-DO-855)

(Rev. 11/2005)
Rule 69H-1.003