Form DFS-DO-855 "Statement - Lightning Losses - State Risk Management Trust Fund" - Florida

What Is Form DFS-DO-855?

This is a legal form that was released by the Florida Department of Financial Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2005;
  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form DFS-DO-855 by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

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Download Form DFS-DO-855 "Statement - Lightning Losses - State Risk Management Trust Fund" - Florida

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Statement - Lightning Losses (DFS-DO-855)
State Risk Management Trust Fund
Statement - Lightning Losses
*NOTE: A SEPARATE STATEMENT IS REQUIRED FOR EACH BUILDING.
Certificate #:
Building #:
(#-###-##)
Building Name:
Date of Loss:
Time of Loss:
:
AM
AM
(MM/DD/YYYY)
List all equipment damaged by this strike:
Was a lightning protection system or arrestor system in place?
Yes
No
If yes, was it damaged?
Yes
No
Explain
State Physical Evidence or Reasons Why Loss Appeared to be
Result of Lightning:
Attach Photo of Physical Evidence Showing Lightning Damage:
no file selected
Uploaded Photos of Physical Evidence Showing Lightning Damage:
Note: The photo that you may attach must either be in GIF or JPEG format. Additional Attachments will be permitted following successful
submission of the form. A link will be provided.
Approximate Date of Previous Lightning Losses:
(MM/DD/YYYY)
It is my firm conviction that this loss was a result of lightning and was not occassioned by low voltage, a power surge, a mechanical
breakdown or because of a defect in the equipment.
Repairman or Licensed Electrician Name:
Name:
Title:
Phone Number:
Date:
Electronic Signature:
*
By placing your initials here, you are thereby signing this document with your signature.
Clear Form
Submit
Save As
Print Form
electronic version (DFS-DO-855)
(Rev. 11/2005)
Statement - Lightning Losses (DFS-DO-855)
State Risk Management Trust Fund
Statement - Lightning Losses
*NOTE: A SEPARATE STATEMENT IS REQUIRED FOR EACH BUILDING.
Certificate #:
Building #:
(#-###-##)
Building Name:
Date of Loss:
Time of Loss:
:
AM
AM
(MM/DD/YYYY)
List all equipment damaged by this strike:
Was a lightning protection system or arrestor system in place?
Yes
No
If yes, was it damaged?
Yes
No
Explain
State Physical Evidence or Reasons Why Loss Appeared to be
Result of Lightning:
Attach Photo of Physical Evidence Showing Lightning Damage:
no file selected
Uploaded Photos of Physical Evidence Showing Lightning Damage:
Note: The photo that you may attach must either be in GIF or JPEG format. Additional Attachments will be permitted following successful
submission of the form. A link will be provided.
Approximate Date of Previous Lightning Losses:
(MM/DD/YYYY)
It is my firm conviction that this loss was a result of lightning and was not occassioned by low voltage, a power surge, a mechanical
breakdown or because of a defect in the equipment.
Repairman or Licensed Electrician Name:
Name:
Title:
Phone Number:
Date:
Electronic Signature:
*
By placing your initials here, you are thereby signing this document with your signature.
Clear Form
Submit
Save As
Print Form
electronic version (DFS-DO-855)
(Rev. 11/2005)