Affidavit of Inspection
for Risk Management Division
85 State House Station
Augusta, ME  04333
1-800-525-1252
PAGE 1

PLEASE PRINT OR TYPE
OWNER’S INFORMATION	
EQUIPMENT OWNED BY	CONTACT PERSON	TELEPHONE NUMBER

			
			
ADDRESS	RMD FILE NUMBER	

CITY	STATE	ZIP CODE	DATE  & TIME OF LOSS	
			     /     /	______:______	AM
PM	
WAS A SURGE PROTECTOR OR UPS USED?     □ YES      □ NO        IF YES, LIST

_____________________________       _____________________________       ____________________________   
                       MAKE                                                   MODEL                                               SERIAL NUMBER	
HAVE THERE BEEN PREVIOUS RELATED PROBLEMS?       □ YES    □ NO        IF YES, EXPLAIN _____________________________________________________________________________________________

_____________________________________________________________________________________________
	
BY WHOM IS POWER FURNISHED? (COMPANY)

	WAS THERE SIMILAR DAMAGE NEARBY?   □ YES  □ NO
IF YES, EXPLAIN 

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________
	
DESCRIBE ITEMS THAT
ARE BEING CLAIMED	MANUFACTURER	PART NUMBER	DATE OF 
PURCHASE	
1.  			/     /	
2.			/     /	
3.			/     /	
4.			/     /	
NOTE: Save and preserve all damaged parts for Risk Management’s inspection	
CONTACT PERSON’S SIGNATURE                                                          PHONE

 X                                                                                                        	DATE
      
               /            /	

Affidavit of Inspection
For Risk Management Division
85 State House Station
Augusta, ME  04333
1-800-525-1252
PAGE 2
PLEASE PRINT OR TYPE
REPAIRER’S AFFIDAVIT	
REPAIRER’S NAME

	COMPANY	
STREET ADDRESS	CITY	STATE	ZIP CODE	TELEPHONE

(           )	
WAS THERE ANY ARCING OR BURNING AT THE SERVICE ENTRANCE OR TO DISTRIBUTION EQUIPMENT IN THE BUILDING?	□ YES      □ NO	
IN MY INDEPENDENT PROFESSIONAL OPINION, THE PROBABLE CAUSE OF LOSS OR DAMAGE WAS (CHECK ONE)	
□	AGE OF EQUIPMENT	□	LIGHTNING (if lightning, see below)	
□	AN ABNORMAL POWER SURGE	□	MANUFACTURING DEFECT	
□	CONTINUAL VARIATIONS IN THE POWER SUPPLY	□	MECHANICAL BREAKDOWN OF MECHANICAL OR ELECTRICAL COMPONENTS	
□	ERRORS OR OMISSIONS IN DESIGN	□	PHYSICAL SHOCK OR IMPACT	
□	EXPLOSION	□	WATER (OR OTHER LIQUIDS)	
□	FAULTY CONSTRUCTION	□	WORK UPON THE PROPERTY AND/OR IMPROPER INSTALLATION	
□	FIRE	□

	OTHER (EXPLAIN)
_______________________________________

_______________________________________	
□	GRADUAL DETERIORATION (CORROSION, RUST, DAMPNESS, DRYNESS, COLD OR HEAT, WEAR & TEAR			
NOTE: Save and preserve all damaged parts for Risk Management’s inspection	
REPAIRER’S SIGNATURE

X	DATE
            
                  /        /	
If loss was caused by lightning, please describe how the path of high-voltage traveled to damaged items, and describe in detail (listing all parts which were replaced) what physical evidence you have observed to lead you to the conclusion that the loss was caused as a result of lightning and how it was conducted.