COPE

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 1:			Town:			Zip Code	

INSURANCE INFORMATION FOR LEASED PREMISE

 	

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: Building has a central station security system:
Building has an employee key card system:

Yes	No
Yes	No
Yes	No

Cost/limit of 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

1 Post office boxes and rural route numbers are unacceptable. The 911 address is required.

O:\WPFS\FORMS\UNDERWRITING\COPE FOR LEASED SPACE.doc x	Revised 07/21/2023