RISK MANAGEMENT 
REQUEST TO ADD INSURANCE TO A VEHICLE
*liability insurance is required for state vehicles and various equipment https://legislature.maine.gov/statutes/14/title14sec8104-A.html

AGENCY:                             
YEAR:                                   
MAKE:                                  
MODEL:                               
VIN:                                       
COST NEW (not purchase price):                         
PERMANENTLY AFFIXED EQUIPMENT COST:                         
OWNED OR LEASED?                                              
INTENDED USE?                                                       
*OUT OF STATE TRAVEL?                                       
DESIRED EFFECTIVE DATE:                                     
**PHYSICAL DAMAGE COVERAGE Y or N?       

Person requesting insurance                             
Phone #                       Email                           

*Out of state travel must be preapproved for insurance coverage.
**physical damage insurance is optional; cost varies by vehicle type.
As a reminder, non-employee drivers/operators must be pre-approved by our office with a Vehicle Use Agreement. 

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