State of Wisconsin

Department of Administration

Division of State Agency Services

DOA-6740 (C04/2001)

 

Please return to:

Risk Management

21 N. Park Street, Suite 5301

Madison, WI  53715

FAX  608-262-9082

Lightning Losses Affidavit

 

 

Date

 

 

To Risk Management:  ____________________________________________________________________________________

I inspected and/or repaired this damaged item: 

 

 

Model Number:

 

Serial Number:

 

Year/Model:

 

 

Date of Purchase:

 

Purchase Price:

 

Size?

 

Place Purchased:

 

Owned by (Dept name):

 

 

Campus Address:

 

 

Date of Loss:

 

Time of Loss:

 

 AM

 PM

 

 

Are damaged item(s) available for inspection? Where?

   

If not, why?

 

 

This damage was solely due to lightning and no other cause whatever because:

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Repair Person

 

 

Print Name of Repair Person

 

 

Firm Name

 

 

Firm Address (Street, City & State)