Risk Logic Inc.
Crum & Forster — A Fairfax Company

Fire System Impairment Notification Form

Carrier:*

Select carrier to enable the rest of the form.

Please check:*
Location:*

Street Address

City

State / Province

Postal / Zip Code

Country

Date of impairment:

Month

Day

Year

 

Time of impairment:

Hour

Minutes

 

Anticipated date to restore:

Month

Day

Year

 

Anticipated time to restore:

Hour

Minutes

 

Does this impairment result from a loss?
Date restored:

Month

Day

Year

 

Time restored:

Hour

Minutes

 

Precautions taken:
Was a 2-inch drain test performed?
Contact name:*

First Name

Last Name

Telephone number:*
-

Area Code

Phone Number

Fax number:
-

Area Code

Phone Number

E-mail:

This address will be CC'd on the notification email