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Please press the "Tab" key to move between the fields of this form.
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Name of Insured
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Agent |
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Email Address
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Telephone |
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How You Found Us
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Other |
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Total Annual Receipts
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How many hours a day are you open?
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$
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Equipment location
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Describe any water entering the equipment area
during the past five years due to flood, rising water, or
leakage of public water mains.
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How is access to equipment restricted to
authorized employees and patients?
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Please describe any fire and or smoke
detection equipment.
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Does the heat/smoke detection equipment automatically shut down the electrical and/or ventilation system?
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Yes No
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What type of alarms are
used to protect the equipment?
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Please describe any
fire suppression system in place.
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Is the equipment in a separate area cut off from the remainder of the building by walls with at least a 1-hour fire-resistive rating?
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Does this separate area have a separate ventilation system? |
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Yes No
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Yes No |
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Does this separate area have smoke-activated automatic dampers?
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Is there a master emergency shut-down switch near the room exit? |
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Yes No
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Yes No |
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How is your equipment protected from power
interruption?
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Do you have a program to periodically inspect and maintain your equipment?
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Yes No
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What procedures are
performed monthly?
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What procedures are
performed quarterly?
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How often is your
equipment inspected and serviced by an outside contractor?
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Business Interruption Coverage
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How long would it take
to secure a replacement unit in the event of a failure of a
unit?
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Is a temporary unit
available during an extended shut down of a unit?
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Comments
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