Protective Devices

PLM is dedicated to the safety of your business.

We understand that in order to properly maintain your protective devices or due to unexpected problems, you may need to temporarily take them out of service.

When this time comes, please fill out the Protective Device Impairment Incident form below to document your impairment, ensure internal and external authorities have been notified, and implement proper safety steps. PLM seeks to ensure that these devices are restored to their full functionality in a timely manner so they can go back to effectively protecting your operations.

Protective Device Impairment Incident Form

Entire form must be filled out. Completed forms are forwarded to our Customer Service Department upon submission. Please enter “N/A” into any field which is not applicable.

Caller/Notifier Name:*
Caller/Notifier Phone:*
Contact Email:*
Policyholder Name:*
Location:*
Fax Phone:
Person Authorizing Shutdown:*
Position:*
Contact Phone/Cell:*
Describe Building(s) Involved in Shutdown:*
Type of System being disabled (ie: sprinkler, alarm, etc.):*
- Fire Suppression
- Security Alarm
- Other (please describe)
If Other, describe below:*
When will Shutdown Occur?*
MM slash DD slash YYYY
Time of Shutdown*

: Hours

Minutes

AM/PM
How Long Will System Be Shutdown, e.g. hrs/days/etc?*
Reason for Shutdown:*
Who will repair the system?*
Repair Start Date:*
MM slash DD slash YYYY
Repair Start Time:*

: Hours

Minutes

AM/PM
Have the proper personnel in the organization been notified?*
- Yes
- No
NOTE: Alert top management, production management, maintenance personnel and emergency response team that system will be down so they can take necessary safeguards.
Have you notified the Fire Department (Fire System) or Security/Law Enforcement (Alarm System)?*
- Yes
- No
Confirmation that Hazardous Operations will be discontinued immediately:*
- Yes
- No
Includes handling and dispensing of flammable liquids and any hot work (cutting or welding, smoking, etc.)
Describe what activity will occur in the effected building(s) during the shutdown period:*
Confirmation of Increased Fire Protection in area of Impairment:*
- Yes
- No
Example: Establish a fire watch to tour the affected area/building during the entire impairment, obtain additional fire extinguishers, hoses, and other manual firefighting equipment in affected area/building.
Comments
This field is for validation purposes and should be left unchanged.

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PLM is dedicated to the safety of your business.

Protective Device Impairment Incident Form