Emergency Response Information Form
1

Please fill in the relevant details below   
(Please note: Mandatory fields*)

Company Name * Division of * State
Location
Street Address *
Suburb *
City *
State Postcode *
Phone A/H *
Headquarters Location
Street Address *
Suburb *
City *
State Postcode *
HQ Phone A/H *
AUTHORISED PERSON(S) TO CALL US IN
Name *
Title *
Phone *
A/H *
Name
Title
Phone
A/H
Name
Title
Phone
A/H
FACILITY INFORMATION
Building Address *
Suburb *
City *
State *
Phone A/H *
Building Address
Suburb
City
State
Phone A/H
Estimated Type of Building Fire Protection Type of Building
Office Square Metres Free Standing Retail
Production Square Metres Multi-use Mfg
Records Square Metres

Other:

 Single Tenant Other
Computer Room Square Metres  
Landlord Property Manager
Name
Street
Suburb
City
State
Phone
Name
Street
Suburb
City
State
Phone
Presence of Hazardous Materials Surrounding Area Type of Business
Industrial
Downtown

Please specify:

 Strip Centre

Please specify:
Retail
INSURANCE INFORMATION
Insurance Company Insurance Broker
Name
Street
Suburb
City
State
Phone
Name
Street
Suburb
City
State
Phone
Self Insured? Risk Manager OR Insurance Coordinator
If Yes, at what point does insurance start
Yes

Additional Comments
Name
Street
Suburb
City
State
Phone

 

 
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