Fire Protection System Impairment Form

Company Name:

Parent Company:

Policy Number:

Impairment Address:

Number:

Suite/Building:

Street:

City/Place:

State/Province:

Country:

Zip code:

Location of Impairment (i.e. second floor, southeast corner of warehouse, west wing):

Percentage of Building Impaired:

Impairment Authorized by:

Title:

Phone:

Email (Note: Only the original notifying impairment coordinator should close out the impairment):

Email CC (Note: Enter additional valid email address recipients (5 max), separate multiple email addresses with a semi-colon):

Chubb Risk Engineer:

SYSTEM IMPAIRED: Complete this section and click submit to notify Chubb directly of system impairment.

Date System Impaired:

Description of Impairment:

Reason for Impairment:

Preplanned Emergency

Expected Length of Impairment:

This field is required. This field is required.

Expected End Date of Impairment:

Additional Comments: