State Risk Management Trust Fund
Statement - Lightning Losses
*NOTE: A SEPARATE STATEMENT IS REQUIRED FOR EACH BUILDING.
Certificate #:
(#-###-##)
Building #:
Building Name:
Date of Loss:
(MM/DD/YYYY)
Time of Loss:
:
AM
PM
List all equipment damaged by this strike:
Was a lightning protection system or arrestor system in place?
Yes
No
If yes, was it damaged?
Yes
No
Explain
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