RISK MANAGEMENT DIVISION
85 SHS
Augusta, ME  04333
(207) 287-3351
Form can be faxed to 287-4008 or emailed to scott.kibler@maine.gov.
(PLEASE WRITE LEGIBILY IF COMPLETING BY HAND)
Date of loss   Click or tap to enter a date. 
Reported by  Click or tap here to enter text.
Phone Number    Click or tap here to enter text.
Address or location of where incident occurred:   Click or tap here to enter text.

Loss details                 Click or tap here to enter text.

Damages         Click or tap here to enter text.

What contributed to loss             Click or tap here to enter text.

Provide name and phone number of person or entity responsible for damages:       Click or tap here to enter text.

Name and Phone Number of person completing this form  Click or tap here to enter text.