Exact Street Address of office location : 	     	Town: 	     	Zip Code	     	

 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); Retail (29);   Staff Residence (11);  Storage (3);
   Vacant (4) Other - Describe:      

Agency area 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