Private Client Group - Wildfire Protection Unit

AUTHORIZATION FORM

I am the owner of the residence indicated below, and I have a homeowners insurance policy covering this residence through Private Client Group, a division of Chartis and underwritten by Chartis Property Casualty Company or an affiliate (“Chartis”). I hereby authorize members of the Wildfire Protection Unit to enter my property in order to provide a fire retardant application (the “treatment”), as needed or appropriate, in the event that my residence is threatened by a wildfire.

I understand that once I execute this authorization, members of the Wildfire Protection Unit, which includes Chartis employees, consultants, and third party vendors, can enter my property at any time during a wildfire in order to apply an emergency treatment. It is the Wildfire Protection Unit’s goal to provide the treatment whenever a residence is threatened by a wildfire that is actively burning within approximately three miles of a residence to be treated.

I understand and acknowledge that the services provided by the Wildfire Protection Unit, including the treatment, may not prevent damage to my property or residence from wildfires. I also understand that there is no guarantee that the Wildfire Protection Unit will be able to apply the treatment to my property before a wildfire damages my property. I HEREBY WAIVE ANY CLAIM AGAINST CHARTIS FOR DAMAGES DUE TO EITHER PERSONAL INJURY OR PROPERTY DAMAGES ARISING OUT OF THE TREATMENT OR LACK OF TREATMENT, OF MY PROPERTY. I AGREE THAT THE SERVICES PROVIDED BY CHARTIS ARE “AS IS” AND CHARTIS SPECIFICALLY DISCLAIMS ALL WARRANTIES TO THE SERVICES EXCEPT AS SPECIFICALLY STATED HEREIN. This waiver does not apply to damage that may occur due to a fire.

I understand that all fees for this emergency service and the treatment will be paid by Chartis, and as a policyholder I will not be charged for this service. Chartis has the right to terminate this service at any time and for any reason. I understand that this service will automatically terminate if I am no longer a policyholder. I also understand that my participation is totally voluntary. Additional information regarding other services, such as permanently installed fire mitigation systems, can be obtained by calling the Risk Management Resources Hotline: 800 899 2409.

Homeowner should consult with the local fire department, wildfire mitigation personnel or local forest service personnel regarding removal of vegetation and other fuel sources for fires around the home.

All fields are required.

By checking this box, I hereby agree to the above terms.

Title

First Name

Last Name

Street Address:

City:

State:

Zip:

This information will only be used by Private Client Group and only for the purposes of contacting you during an emergency situation. Please be assured that we will not share any of the information that you provide to us for any other purpose other than for this program.

Priority 1 Phone Number:

Priority 2 Phone Number:

Priority 3 Phone Number:

Priority 4 Phone Number:

Priority 5 Phone Number:

Email address: (An email confirmation will be sent to this address)

Do you wish to receive non-emergency email updates from the Wildfire Protection Unit?
Yes No

Alternate contact person during an emergency:

Phone:

Access/Gate codes:

In addition to your on-site wildfire consultation, you are eligible to receive a complimentary disaster preparedness assessment to help determine how to better prepare your home and family for disaster. Click HERE to learn more about the Emergency Preparedness program and to schedule a consultation.

Contact person for non-emergency related issues including complimentary onsite consultation:

Name:

Phone:

Insurance agent: