Fire Safety Equipment Claim Form
Please fill out the form to submit your claim for fire safety equipment.
Claimant Full Name
First Name
Last Name
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.
Equipment Type
Please Select
Fire Extinguisher
Smoke Detector
Fire Blanket
Emergency Exit Sign
Fire Hose Reel
Date of Purchase
-
Month
-
Day
Year
Date
Date of Incident
-
Month
-
Day
Year
Date
Description of Incident
Upload Proof of Purchase or Damage
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: