State Risk Management Trust Fund
Statement - Lightning Losses
*NOTE: A SEPARATE STATEMENT IS REQUIRED FOR EACH BUILDING.
Date of Loss:
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:
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:
By placing your initials here, you are thereby signing this document with your signature.
electronic version (DFS-DO-855)