Fire Protection System

Impairment Notification & Restoration Form

From:	Send To:

Name:
Company:
Local Name:
Street Address:	Allianz Risk Consulting
City, State/Region:	E-mail: impairments@allianz.com
Postal Code:
Country:
Telephone:
E-mail:

Please complete Part A for initial impairment notification and Part B after restoration.

Part A – Impairment Notification

Notification should be submitted only for impairments exceeding 10 continuous hours. Notify at least 48 hours prior to a planned impairment and as soon as possible for an emergency (unplanned) impairment.

Impairment Type:	Planned	Emergency
System(s) / Equipment Impaired:
Area(s) Affected:
Reason for Impairment:
Impairment Date (dd/mm/yy) & Time:
Anticipated Restoration Date (dd/mm/yy) & Time:

Precautions Taken: (answer all applicable questions)	Yes	No
Have managers, supervisors, security & other relevant staff been notified of impairment, increased fire risk, and necessary precautions?
Have all hazardous operations, including hot work, flammable liquid use, etc., been prohibited in the area?
Has smoking been prohibited in the area?
Has temporary fire protection (i.e. fire extinguishers, hoses, etc.) been provided? (comment below)
Is affected area continuously occupied or has a continuous fire watch been provided?
Has the fire brigade / department been notified?
Has the alarm monitoring company been notified?
Will work be continuous until protection is restored?

Comments:

Part B – Impairment Restoration

Restoration Date (dd/mm/yy) & Time:
Comments: