Online Services for VERLAN Insureds - Impairment Form
Company Name:        Your Name:       Location of Impairment:       Impairment Date & Time:        Anticipated Duration        System impaired (Main water supply, Fire pump, Sprinkler system- area protected, other: alarm systems, carbon dioxide, etc.):     Occupancy of impaired area (Manufacturing, Warehouse, Office, Lab, Other):       Purpose of impairment (Repair, Alteration to System, Other):      Protective measures taken (Fire watch, Additional Portable Extinguishers in Area, Fire Department Notified, Manufacturing Operations Suspended, Other):      Additional Comments: