Your Agency: 	     	
Agency Contact Name:	     	Contact Phone:	     	
Contact E-mail:	     	Contact Fax: 	     	
Exact Street Address of  premise : 	     	Town: 	     	Zip Code	     	
Building property name: 	     	Risk Mgmt Mcode:       or   unknown	

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	

Year of construction of building (if known or best guess):       
Number of floors (do not count unfinished basement and attic)      
Is there a basement/crawl space? Yes    No     Is the basement finished Yes     No
Approximate square footage of building - do not include basement, attic or mezzanine: 	      sq. feet
Number of elevators in building:           

Boiler and/or pressure vessels – In this building, how many units may require State inspection?
Number of boilers:        Number of pressure vessels:      
 
Building 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:      

Your agency’s occupancy type (check one - only the most prevalent):
Auditorium (18);  Classroom (2);  Day Care (33); Dormitory (10);   Gym (12); Laboratory (5);
Maintenance Shop (6); Office (1); Garage (35);   Staff Residence (11);  Storage (3);  Vacant (4)
Other - Describe:      

Building is:     100% Sprinklered   Partially Sprinklered – state %          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

Cost/limit of insurance desired:  Building: $        Contents $        Effective Date:      

IF POSSIBLE, PROVIDE A PHOTOGRAPH OF THE FRONT OF BUILDING 

Email this form to amber.dangler@maine.gov 

Questions?  Call 287-3351  
Fax 207-287-4008