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 an unfinished basement? Yes    No      Is there an unfinished attic? Yes     No
Approximate total area of building - do not include unfinished basement or attic: 	      sq. feet
Of the total area, approximate area that your agency occupies:        sq. feet
Number of elevators in building:          Does building have central air conditioning? Yes     No

Boiler and/or pressure vessels – In this building, how many units require State inspection?
Number of boilers requiring inspection:        Number of pressure vessels requiring inspection:      
Are there boilers or heating units in this building that do not require State inspection?  Yes   No
If yes, optional enhanced insurance coverage is available for a small extra premium charge.  Are you interested in being contacted by Risk Management about this enhanced coverage?  Yes   No

If your agency does not occupy 100% of the useable space in this building, this section must be completed.
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); 
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); Retail (29);   Staff Residence (11);  Storage (3); 
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
Replacement cost insurance desired:  Building: $        Contents $        Effective Date:      

Questions?  Call 287-3353  
Either fax this form to 287-4008 or mail it to:	
 State of Maine, Risk Management Division, 85 State House Station, Augusta, ME 04333-0085  
FOR RISK MANAGEMENT DIVISION USE ONLY	INSPBY:		INSPDATE: