Fire Suppression Application

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Work Email * Required

First Name	* Required
Last Name
Comments

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Business name *
Location
Phone *
Email *
Contact name *
Year Established
# of Owners
# of Field Employees
# Vehicles
Owner Duties
Type of business (please check all that apply)
Sprinkler Systems Contractor (Water Based Systems)	Yes No
Sprinkler Systems Annual Sales
Sprinkler Systems Field Payroll(exclude owners payroll)
Restaurant/Special Systems Contractor	Yes No
Restaurant/Special Systems Annual Sales
Restaurant/Special Systems Field Payroll(exclude owners payroll)
Fire Extinguisher Systems Contractor (Portable)	Yes No
Fire Extinguisher Systems Annual Sales
Fire Extinguisher Systems Field Payroll(exclude owners payroll)
Alarm/Security Systems Contractor	Yes No
Alarm/Security Systems Annual Sales
Alarm/Security Systems Field Payroll(exclude owners payroll)
Hood Cleaning and Service	Yes No
Hood Cleaning and Service Annual Sales
Hood Cleaning and Service Field Payroll(exclude owners payroll)
Other	Yes No
Other Annual Sales
Other Field Payroll(exclude owners payroll)
Please indicate the business sectors represented by the insured’s customers and show the estimated percentage of the insured’s overall receipts generated by each
Operations
% New Install
% Retrofit
% Service/Repair
% Testing
% Design
Client Base
% Apartments
% Hotel/Motel
% Retail/Office
% Restaurants/Food Svc
% Other (describe)
% Condominiums
% Single Family Homes
% Industrial/Manufacturing
% Hospitals/HealthCare
Does the insured hire subcontractors?	Yes No
If Yes, annual cost of work subcontracted
Type of work subcontracted
Does the insured perform work on aircrafts, automobiles, mobile equipment, boats, and yachts?	Yes No
If Yes, please describe
Does the insured inspect, test or certify systems installed by others?	Yes No
If Yes, what percentage of the Insured’s Entire Business receipts are generated from these services?
Does the insured use CPVC piping for any sprinkler installations?	Yes No
If Yes, what percentage of total receipts are generated from these services?
Does the insured sell safety equipment other than fire extinguishers?	Yes No
If yes, total sales
If Yes, please list
Does the insured perform work in buildings over 5 stories?	Yes No
Over 20 stories?	Yes No
Does the insured install/monitor Medical Emergency/ Nurse call systems?	Yes No
If yes, total sales call systems
Is alarm monitoring subcontracted out or handled by a third party?	Yes No N/A
If yes, total cost subcontracted
Does the insured design sprinkler systems, alarm systems. or extinguisher systems?	Yes No
If Yes, what qualifications do the designers have?	Nicet III PE(Professional Engineer) Other
If Other, Type Qualification
If Yes, does insured provide design work for others?	Yes No
Current Carrier
Premium
Expiration Date
Association Memberships
Please describe in detail any claims from the past 5 years

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Fire Suppression Application

Type of business (please check all that apply)

Please indicate the business sectors represented by the insured’s customers and show the estimated percentage of the insured’s overall receipts generated by each

Operations

Client Base