LIGHTNING AFFIDAVIT - Georgia

Risk Management Services Property Program
Lightning Affidavit
|Insured Agency/Department _________________Address ______________________________ |
| |
|1. Date of Loss _________________ 2. Time of Loss ________________ [ ] am [ ] pm |
| |
|3. Were fuses blown or circuit breaker thrown? _______________________________________ |
|Amperage of fuses? ______________________________________________________ |
| |
|4. List all damages caused by lightning: ______________________________________________ |
|______________________________________________________________________________ |
| |
|5. Items Involved: _______________________________________________________________ |
|______________________________________________________________________________ |
| |
|6. Manufacturer’s Name __________________________________________________________ |
| |
|7. Age of appliance(s) ____________________________________________________________ |
| |
|8. Item grounded or lightning arrestor? _____________________________________________ |
| |
|9. State reasons why loss appeared to be a result of lightning. ___________________________ |
|______________________________________________________________________________ |
| |
|10. Litmus paper test made? ___________________ Smell Acidity? _______________________ |
| |
|11. Name and address of power company furnishing electricity? _________________________ |
|______________________________________________________________________________ |
| |
|12. Approximate date of previous lightning losses. ____________________________________ |
| |
|It is my firm conviction that this loss was a result of lightning and was not occasioned by low voltage, mechanical |
|breakdown, or a defect in the appliance. |
| |
|Signed: _______________________________________________________________________ |
|Licensed Electrician Date |
| |
|Address: ______________________________________________________________________ |
| |
|Notary: State of Georgia, _______________ County. |
|Subscribed and sworn to before me this ___ day of _______, 20 ___ by the affiant, who personally appeared before me. |
| |
|__________________________________________________ ______________________________ |
|Notary Public Signature My Commission Expires |
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