RISK MANAGEMENT
INSURANCE REQUEST - EQUIPMENT

ADVANCE NOTICE FOR INSURANCE IS REQUIRED FOR TIMELY PROCURMENT
Self-insurance may not be available and may require commercial insurance.

AGENCY:                             
ASSET:                             
YEAR:                                   
MAKE:                                  
MODEL:                               
VIN:                                       
COST NEW (not purchase price):                         
OWNED, LEASED OR DONATED?                                              
INTENDED USE OF EQUIPMENT?                                                       
WHO IS TRANSPORTING EQUIPMENT?                                                       
WHO INSURES TOWING VEHICLE?                                                       
IS LEASE / RENTAL AGREEMENT ATTACHED?                                                       
RENTAL OR LEASE TERM:                                      
Person requesting insurance                             
Phone #                       Email                           

Liability insurance is required for state equipment https://legislature.maine.gov/statutes/14/title14sec8104-A.html

Questions? Call us 287-3351
Fax (287-4008) or email this form to 
Jen Maddox Jen.Maddox@maine.gov