Your Agency: 	     	Lease Number:	     	
Check One:  New Lease   Renewal  Lease  Other - Describe:         	     	
Agency Contact Name:	     	Contact Phone:	     	
Contact E-mail:	     	Contact Fax: 	     	
Exact Street Address of leased premise : 	     	Town: 	     	Zip Code	     	

Check the type of construction that best describes the building:
 (1) Combustible (typically wooden buildings)	 (2) Masonry structures with combustible frames or interiors	
 (3) Metal structures (all metal roof, frame and walls)	 (4) Masonry structures with masonry or metal framing	
 (5) Buildings with a 1-to-2-hour fire resistive rating	 (6) Buildings with a 2 or more-hour fire resistive rating	

Total area your agency occupies with this lease:	      sq. feet
 
Leased space occupancy type(s) - check as many as are applicable for this building: 
Auditorium (18);  Classroom (2);  Day Care (33); Dormitory (10);   Gym (12); Laboratory (5);
Maintenance Shop (6); Office (1); Retail (29);   Staff Residence (11);  Storage (3);  Vacant (4)
Other - Describe:      

Leased Space is:     Sprinklered   Not sprinklered at all
Building has a central station smoke detection system:	 Yes    No
Building has a central station security system:		 Yes    No
Building has an employee key card system: 			 Yes    No

Replacement cost insurance desired:  Contents $        Effective Date:      

Questions?  Call 287-3351
Either fax this form to 287-4008 or mail to:	
 State of Maine, Risk Management Division, 85 State House Station, Augusta, ME 04333-0085