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Residential Automatic Water Shut Off Valve Evaluation Form
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Automatic Water Shut Off Valve Evaluation
An automatic water shut off valve device will monitor the water in your residence's pipes for unusual water flows and take action when necessary. If an abnormality in the flow of water is detected by the technology, the device will turn a valve that will shut the water off to the house automatically. This form will help identify the characteristics of your home that should be understood prior to installing one of these devices as well as gather information that could help streamline the installation process.
What is your first name?
*
What is your first name?
What is your last name?
*
What is your last name?
What is your email address?
*
What is your email address?
What is the address of the property you would like to mitigate water damage in?
What is the address of the property you would like to mitigate water damage in?
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
What type of residence is this?
What type of residence is this?
Single family home
Multi-family residence
Condominium / Cooperative
Does this multi-family residence have individual plumbing lines and meters for each unit?
Does this multi-family residence have individual plumbing lines and meters for each unit?
Yes
No
Not sure
Does this condominium or cooperative have its own plumbing lines and meter?
Does this condominium or cooperative have its own plumbing lines and meter?
Yes
No
Not sure
Residential Plumbing Details
What is the diameter (in inches) of the water supply pipe(s) entering this residence?
What is the diameter (in inches) of the water supply pipe(s) entering this residence?
3/4 inch
1 inch
1 1/4 inches
1 1/2 inches
2 inches
3 inches
Not sure
Does this residence have a fire suppression sprinkler system installed?
Does this residence have a fire suppression sprinkler system installed?
Yes
No
Not Sure
Does the fire suppression sprinkler system have its own water supply line?
Does the fire suppression sprinkler system have its own water supply line?
Yes
No
Not sure
Does this property have any outdoor water features? (Ie. Pool, spa, irrigation, etc...)
Does this property have any outdoor water features? (Ie. Pool, spa, irrigation, etc...)
Yes
No
Please select all the outdoor water features present on this property.
Please select all the outdoor water features present on this property.
Pool
Spa
Lawn irrigation
Fountain
Other
What are the other outdoor water features on this property?
What are the other outdoor water features on this property?
Does your pool/spa have an automatic fill line?
Does your pool/spa have an automatic fill line?
Yes
No
Not sure
Does this residence have a water filtration system?
Does this residence have a water filtration system?
Yes
No
Not sure
Please select the type of water filtration system you have at this residence.
Please select the type of water filtration system you have at this residence.
Whole house water softener
Whole house reverse osmosis filter
Under the sink reverse osmosis filter
Not sure
Does this residence have a hot water recirculation pump?
Does this residence have a hot water recirculation pump?
Yes
No
Not sure
Are you familiar with the location of the manual water shut off valve is for this residence?
Are you familiar with the location of the manual water shut off valve is for this residence?
Yes
No
Not sure
Is there an electrical outlet within 15 feet of the manual water shut off valve?
Is there an electrical outlet within 15 feet of the manual water shut off valve?
Yes
No
Not sure
Would you like to upload a picture of your manual water shut off valve or other plumbing set up for us to view?
Would you like to upload a picture of your manual water shut off valve or other plumbing set up for us to view?
Yes
No
Please feel free to upload pictures here.
Please feel free to upload pictures here. (Max 128 MB)
Drop files here or
Select files
Max. file size: 128 MB.
Does this property have any other structures, besides the main residence, that has running water?
Does this property have any other structures, besides the main residence, that has running water?
Yes
No
Please provide a brief description of the other structure(s) that has/have running water.
Please provide a brief description of the other structure(s) that has/have running water.
Device Installation Details
Do you have a plumber?
Do you have a plumber?
Yes
No
What is your plumber's business name?
What is your plumber's business name?
Is it convenient/possible to install a device inside this residence? (Including a garage)
Is it convenient/possible to install a device inside this residence? (Including a garage)
Yes
No
Not sure
Do you want to be able to monitor and control the water flow at this residence with your smart phone? (Ie. iPhone, Android)
Do you want to be able to monitor and control the water flow at this residence with your smart phone? (Ie. iPhone, Android)
Yes
No
Not sure
Does this property have wireless internet available?
Does this property have wireless internet available?
Yes
No
Does this residence have a monitored alarm system?
Does this residence have a monitored alarm system?
Yes
No
Do you want the automatic water shut off valve to be connected to the monitored alarm system?
Do you want the automatic water shut off valve to be connected to the monitored alarm system?
Yes
No
Not sure
What is the name of the alarm company?
What is the name of the alarm company?
Is this automatic water shut off valve device installation being required by your insurance company?
Is this automatic water shut off valve device installation being required by your insurance company?
Yes
No
Is your insurance company's requirement to install this device related to a recent water damage claim?
Is your insurance company's requirement to install this device related to a recent water damage claim?
Yes
No
Not sure
Comments & Questions
Please enter any additional remarks below.
Please enter any additional remarks below.
Disclaimer
*
Any information or product suggestions we provide are purely for your convenience and is based entirely on information supplied by you. All decisions about which device to install in a home should always be verified by a qualified plumbing expert.
I have read this disclaimer
AJG (Ericson) Service
860-868-7361
www.ericsoninsurance.com
GGB.WashingtonDepot.Service@ajg.com
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