Philadelphia Insurance Company Philadelphia Indemnity Insurance Company Maguire Insurance Agency, Inc.

MONTHLY FIRE PROTECTION INSPECTION FORM

Facility Inspector Location Date

INSPECTOR INSTRUCTIONS:

THE FOLLOWING ITEMS SHOULD BE REGULARLY INSPECTED, TESTED, AND MAINTAINED TO HELP ENSURE COMPLETE AND TOTAL RELIABILITY OF YOUR FACILITIES FIRE PROTECTION SYSTEMS. COMPLETE THE BELOW CHECKLIST IN ACCORDANCE WITH THE FREQUENCY RECOMMENDED. "NON-BOLDED" RESPONSES SHOULD BE EXPLAINED IN THE ADDITIONAL COMMENTS SECTION. DO NOT COMPLETE A PARTICULAR SECTION UNLESS YOU HAVE PERSONALLY INSPECTED OR TESTED THAT PARTICULAR PIECE OF FIRE PROTECTION EQUIPMENT. A COPY OF THE INSPECTION FORM SHOULD BE SENT TO THE DESIGNATED PERSON IN CHARGE FOR NECESSARY ACTION.

THE FOLLOWING CHECKLIST IS INTENDED TO PROVIDE OUR CUSTOMERS WITH THE GENERAL INFORMATION NEEDED TO COMPLY WITH MOST LOCAL AND NATIONAL AGENCIES. THIS FORM SHOULD NOT BE INTENDED AS A SUBSTITUTE FOR ANY ADVICE PROVIDED BY YOUR

OCAL AUTHORITY HAVING JURISDICTION. L

INSPECT THESE ITEMS AT LEAST MONTHLY

WATER SUPPLY AND FIRE ALARMS (For Buildings with Fire Sprinklers) NA__ Yes No Yes No PUBLIC WATER SUPPLY IN SERVICE FIRE ALARM SYSTEM OPERATIONAL PUBLIC WATER PRESSURE PSI CHANGE FROM PREVIOUS MONTH

CENTRAL STATION RECEIVED ALL SPRINKLER WATERFLOW AND TAMPER ALARMS

2 IN. DRAIN TEST PERFORMED FIRE DEPARTMENT CONNECTION ACCESSIBLE DID WATER MOTOR GONG OPERATE FIRE DEPARTMENT CAPS IN PLACE INSPECTORS TEST CONNECTIONS FLOWED CLEAR PUBLIC FIRE HYDRANTS ACCESSIBLE

GENERAL COMMENTS:

SPRINKLERS / NA ___ Yes No Yes No STOCK MORE THAN 18 IN. FROM SPRINKLER HEADS SPRINKLER HEADS OR PIPING CORRODED SPRINKLER HEADS FREE OF PAINT, DUST OR RESIDUE SPRINKLER HEADS GREATER THAN 50 YEARS OLD ANY HANGING ITEMS ON PIPING OR HEADS ANY HEADS DISCONNECTED OR NEEDED SPRINKLER HEADS UNOBSTRUCTED BY PARTITIONS SPARE SPRINKLER HEADS AVAILABLE

GENERAL COMMENTS:

FIRE PUMP & TANK / RESERVOIR (IF APPLICABLE) NA____ Yes No Yes No FIRE PUMP AUTOMATICALLY STARTED BY PRESSURE DROP: DIESEL: (WEEKLY) ELECTRIC: (MONTHLY)

BATTERIES PROPERLY CHARGED AND FREE OF CORROSION

PUMP RUN FOR MINIMAL TIME: DIESEL PUMP (30 MIN.) ELEC. PUMP (10 MIN.)

TANK / RESERVOIR HEATING SYSTEM WORKING PROPERLY

PACKING COOL DURING OPERATION TANK/ RESERVOIR FULL OR WAS IT OVERFLOWED PUMP ROOM HEATED & VENTILATED TANK LEVEL INDICATOR OPERATIONAL DIESEL FUEL TANK AT LEAST 2/3 FULL RESERVOIR SCREEN CLEANED FROM DEBRIS

GENERAL COMMENTS: DRY PIPE, PREACTION, DELUGE (IF APPLICABLE) NA___

Rm. No.1 Rm. No. 2 Rm. No. 3 Rm. No. 4 Rm. No. 5 Rm. No. 6 Rm. No. 7 Rm. No. 8 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No VALVE RM.

HEATED AIR PRESS. PSI PSI PSI PSI PSI PSI PSI PSI

H2o PRESS. PSI PSI PSI PSI PSI PSI PSI PSI GENERAL COMMENTS:

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MANUAL PROTECTION Yes No Yes No ADEQUATE NUMBER OF FIRE EXTINGUISHERS MANUAL PULL STATIONS TESTED PERIODICALLY PROPER EXTINGUISHERS FOR OCCUPANCY INSIDE HOSES ACCESSIBLE EXTINGUISHERS PROPERLY CHARGED INSIDE HOSES IN GOOD CONDITION EXTINGUISHERS PROPERLY LOCATED AND PLACED (HUNG ON SUPPORTS)

PRIVATE YARD HYDRANTS ACCESSIBLE AND IN GOOD CONDITION

GENERAL COMMENTS:

SPECIAL EXTINGUISHING SYSTEMS (IF APPLICABLE) Yes No Yes No SPECIAL EXTINGUISHING SYSTEM IN SERVICE MANUAL ACTUATORS UNOBSTRUCTED DETECTION DEVICES FOR SYSTEM IN SERVICE SYSTEM IS SERVICED BY CERTIFIED CONTRACTOR

GENERAL COMMENTS:

FIRE DOORS, FIRE WALLS Yes No Yes No FIRE DOORS WELL MAINTAINED COMBUSTIBLE STORAGE AT LEAST 3 FT. FROM FIRE DOOR FIRE DOORS FREE FROM OBSTRUCTIONS OR BLOCKAGE

FIRE DOORS PROVIDED WITH PERIODIC MAINTENANCE AND DROP TESTING PROGRAM

FIRE DOOR ARRANGED FOR AUTOMATIC CLOSING

HORIZONTAL PENETRATIONS IN FIRE WALLS PROPERLY SEALED

FUSIBLE LINKS FREE FROM PAINT FIRE WALL IN GOOD STRUCTURAL CONDITION GENERAL COMMENTS:

GENERAL CONDITIONS/ SPECIAL HAZARDS

Yes No Yes No GOOD HOUSEKEEPING NOTED THROUGHOUT MECHANICAL VENTILATION SYSTEMS OPERATING MINIMAL AISLE STORAGE NOTED IN WHSE. AREAS AEROSOLS KEPT IN METAL CABINETS SMOKING REGULATIONS ENFORCED WITH SIGNS POSTED THROUGHOUT

COMPRESSED CYLINDERS PROPERLY STORED AND CHAINED

STORAGE SKIDDED OFF FLOOR IDLE PALLET STORAGE BELOW 6 FT. STORAGE WELL ARRANGED TO PREVENT COLLAPSE ELECTRICAL EQUIPMENT IN GOOD CONDITION COMBUSTIBLE WASTE REMOVED PROMPTLY HEATING SYSTEM IN GOOD CONDITION COMBUSTIBLES COMPLETELY REMOVED FROM COMPUTER /ELECTRICAL/MECHANICAL ROOMS

PROCESS FUEL-FIRED EQUIPMENT IN GOOD CONDITION

DUST/LINT OR OILY DEPOSITS REMOVED FROM CEILINGS, BEAMS OR EQUIPMENT

OUTSIDE YARD STORAGE ADEQUATELY SEPARATED FROM BUILDING

FLAMMABLE LIQUID DISPENSING CONTAINERS PROPERLY GROUNDED

ADEQUATE PROTECTION AGAINST THEFT AND VANDALISM

FLAMMABLE LIQUID DISPENSING CONTAINERS PROVIDED WITH SAFETY RELIEF BUNGS BUILDING ROOF CONSTRUCTION IN GOOD CONDITION FLAMMABLE LIQUID DISPENSING CONTAINERS PROVIDED WITH SELF CLOSING FAUCETS BUILDING ROOF FREE FROM PONDING OR LEAKAGE FLAMMABLE LIQUIDS KEPT IN METAL CABINETS OR PROPERLY DESIGNED ROOM

DOMESTIC VALVES AND PIPES PROPERLY LABELED AND TAGGED

GENERAL COMMENTS:

ADDITIONAL COMMENTS AND RECOMMENDATIONS

SAMPLE ONLY: THIS FORM OR SIMILAR FORM MAY BE REDEVELOPED TO FIT YOUR COMPANY'S SPECIFIC NEEDS. ITEMS THAT DO NOT APPLY CAN BE OMITTED. OTHER ITEMS CAN BE EXPANDED OR NEW ITEMS CAN BE ADDED AS DESIRED. If YOUR LOCATION IS SPRINKLERED, USE THIS FORM IN CONJUNCTION WITH THE SPRINKLER CONTROL VALVE INSPECTION FORM. AFTER COMPLETING THE INSPECTION, ONE COPY OF THE FORM SHOULD BE KEPT ON FILE FOR FUTURE REVIEW, AND ANOTHER COPY SHOULD BE FORWARDED TO MANAGEMENT. MANAGEMENT SHOULD REVIEW FORM AND TAKE CORRECTIVE ACTION ON ALL NOTED DEFICIENCIES.

The information and suggestions presented by Philadelphia Indemnity Insurance Companies in this loss control technical resource form are for your consideration in your loss prevention and risk control efforts. They are not intended to be complete in identifying or reporting on every possible or significant hazard at your premises, preventing possible workplace accidents, or complying with all of the local, state or federal health & safety related laws or regulations. The material enclosed within this loss control reference source is intended and encouraged to be altered or redesigned by you to specifically address your hazards.

InspectorINSPECT THESE ITEMS AT LEAST MONTHLYYesYesYesYesYesYesRm. No.1Rm. No. 2YesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNo

YesYesYesYesYesYesYesYes