Fire Protection System Impairment Form

When fire protection systems (e.g., sprinkler systems, fire detection systems, special extinguishing systems) are impaired for more than eight hours due to an emergency or routine maintenance, complete the following form. The notification will be sent directly to Chubb Risk Engineering Services.

Company Name: *
Parent Company:
Policy Number:
Impairment Address:*
Location of Impairment (i.e. second floor, southeast corner of warehouse, west wing):*
Impairment Authorized by:*
Chubb Risk Engineer:
SYSTEM IMPAIRED: Complete this section and click submit to notify Chubb directly of system impairment.
Date System Impaired:* 
Time System Impaired:* 
Description of Impairment:*
Reason for Impairment:
Expected Length of Impairment:*
Expected End of Impairment:*
Additional Comments:

Precautions Taken:
Public Fire Department Notified Ongoing Patrol of Area Hazardous Operations Stopped
Monitored by Heat/Smoke Detection Standpipe System Available Fire Extinguishers Available
Hydrant Connected to Sprinkler Riser Hot Work Prohibited Smoking Restricted

SYSTEM RESTORATION: Please complete this section when the system is fully restored and click “submit”. 
Date System Restored:* 
Time System Restored:* 
Has the following been completed? Choose One
2" drain test conducted? Yes No
Do 2" drain results compare favorably to past test results? Yes No
Sprinkler alarms tested? Yes No
Central station notified? Yes No
Out of Service tags removed? Yes No
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