Residential Fire Protection Evaluation - Department Form

What is the property owner's first name?

What is the property owner's last name?

What is the property owner's email address?

What is the address of the property being evaluated for fire protection?

Street Address Address Line 2 City State ZIP Code

Fire Department Information

What is the name of the responding fire department?

What is the address of the responding fire department?

Street Address Address Line 2 City State ZIP Code

What is the full name of the fire department contact?

What is the role of the fire department contact?

What is the phone number for the fire department contact?

What is the email address for the fire department contact?

How is the fire department staffed?

Paid fire fighters
Volunteer fire fighters

How many paid fire fighters does the department have?

How many volunteer fire fighters does the department have?

How many pumpers does the fire department have?

What is the pumping capacity of the pumpers? (In gallons per minute)

How many tankers does the fire department have?

What is the pumping capacity of the tankers? (In gallons per minute)

Fire Protection Information

What is the protection class of the property?

What is the response time for this property? (Approximate)

Is there a public fire hydrant within 1,000 feet of the home?

Yes
No
Not sure

What is the nearest water source? (Select all that apply)

Dry hydrant connected to a cistern
Dry hydrant connected to a pond or pool
Pond/Lake
Pool
Other
None

Please provide details about the nearest water source.

What is the distance of the water source(s) from the dwelling? (Approximate)

What is the amount of water available? (Approximate)

Is/are water source(s) accessible to the fire department year-round?

Yes
No
Not sure

Please explain why the water source is not accessible year-round. (Ie. Freezes in the winter)

Are the roads paved and accessible year-round?

Yes
No
Not sure

Are there any physical barriers to the property? (Ie. Gate, bridge, etc...)

Yes
No
Not sure

Please describe the physical barriers.

Is the dwelling clearly visible, with no obstructions, to full-time resident neighbors?

Yes
No
Not sure

Please explain why the dwelling is not clearly visible to resident neighbors.

Please enter any additional comments regarding the fire protection for this property below.

Consent*

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

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Residential Fire Protection Evaluation - Department Form

Fire Department Information

Fire Protection Information

Jennifer Le – CA Lic# 0M68191

RiskRevu^TM Newsletter

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Residential Fire Protection Evaluation - Department Form

Fire Department Information

Fire Protection Information

Jennifer Le – CA Lic# 0M68191

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter