39 Public Square ● P.O. Box A-H ● Wilkes-Barre, Pennsylvania 18703-0020
570-825-9900 ● 800-673-2465 ● www.guard.com
Protective Safeguard
Impairment Notification Form
To report an impairment to a policyholder’s protective safeguard(s), please complete and e-mail this form to
reportimpairment@guard.com. When the impairment period is over, please update the form with the Restoration
Date/Time and e-mail to us again.
Check one: ☐ Initial Impairment Notification
☐ Impairment Restored Notification
(Be sure to complete Box 14 below.)
Location and Contact Information
1. Policy Number (if known):
2. Account/Insured Name:
3. Building/Location Address:
4. City, State & Zip:
5. Submitter’s Name:
6. Daytime/Mobile Phone Number:
7. Email Address:
Impairment Information
8. Type of Impairment:
☐ Planned ☐ Unplanned
☐ Public water supply
☐ Private water supply
☐ Fire pump
☐ F
ire alarm
system
☐ Wet sprinkler system
☐ Dry sprinkler system
☐ Foam system
☐ Kitchen hood system
☐ Dry chemical system
☐ Clean agent system
☐ Other; See comments
9. Reason for Impairment:
☐ Maintenance
☐ System addition or replacement
☐ Damaged piping
☐ Equipment repair
☐ Agent discharged
☐ Other (Use Box 10. Comments to explain)
10. Comments:
11. Location and/or system number(s):
12. Impairment Start Date: ____ - ____ - _______ / Time: _________ ☐ AM ☐ PM
13. Estimated Restoral Date: ____ - ____ - _______ / Time: _________ ☐ AM ☐ PM
14. Actual Restoral Date: ____ - ____ - _______ / Time: _________ ☐ AM ☐ PM
15. Actions taken:
Before/During
☐ System(s) tagged
☐ Fire Department notified
☐ Alarm Company notified
☐ Plant Emergency notified
☐ Hourly fire watch during impairment
☐ Needed materials on hand
☐ Privat
e protection increase
d
☐ Hot Work discontinued in the area(s)
16. Additional Comments:
FLPS061620
