Municipality or County Name:

Contact Person:

Contact Person's Title:

 

Email Address:

Mailing Address:

   

City:

State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Phone Number:

Fax Number:

 

Attach a copy of your Insurance Statement of Values (or building list with square footage & building usage).

 

 

Number of Employees:

Number of Departments:

Infrastructure items not on Statement of Values

Number of Bridges:

Number of Roads:

Fixed Assets Cutoff Amount: $

The purpose for requesting
an inventory and appraisal: Please select Insurance GASB #34 Compliance Both Insurance and GASB #34

 

Have you had any recent acquisitions
of Homeland Security Equipment?