SOP 404.03-att-3: Lightning Affidavit

Division:
Administrative & Finance
Effective Date:
July 1, 2020
Topic Area:
402-405 Policy-Administration and Finance
PowerDMS:
View on PowerDMS
Length:
151 words

Summary

This form is used by GDC agencies to document and report property damage caused by lightning strikes for insurance claim purposes. The affidavit requires detailed information about the date and time of the loss, damage description, equipment specifications, and evidence supporting that lightning (rather than mechanical failure or electrical defects) caused the damage. Completed forms must be retained for five years.

Key Topics

  • lightning damage
  • insurance claim
  • affidavit
  • property damage
  • electrical damage
  • lightning strike
  • equipment damage
  • damage documentation
  • insurance reporting
  • loss documentation

Full Text

SOP 404.03
Attachment 3

7/1/20

DEPARTMENT OF ADMINISTRATIVE SERVICES

# 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. Manufacture’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: _________________________________________________________________
Legible Signature & Title Date

Company Name & Address:
________________________________________________________________________

Notary: State of Georgia, County of _______________.

This _______ day of ____________ subscribed before me this Date and year set out.

Retention Schedule: Upon completion, this form shall be retained for five (5) years and then be
destroyed.

Attachments (4)

  1. Insurance Notice of Loss Form (277 words)
  2. Sworn Proof of Loss Form (349 words)
  3. Lightning Affidavit (151 words)
  4. Property Transfer Form (76 words)
Machine-readable: JSON Plain Text