Fire District Name:

Contact Person:

Contact Person's Title:

 

Email Address:

Mailing Address:

   

City:

State: Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Phone Number:

Fax Number:

 

Attach a copy of your Insurance Statement of Values (or building list with square footage & building usage).

 

 

Number of Employees

Full Time:

Part Time:

Volunteer:

Number of Turn-out Gear:

Number of Air Packs/SCBA:

Type of Fire Fighting:

Does your fire district dispatch EMT/Rescue?

Number of Pumper Trucks:

Number of Tanker/Tender Trucks:

Number of Rescue Vehicles:

Number of Ambulances:

Number of Command Vehicles:

Please list any other Speciality Equipment:

Fixed Assets Cutoff Amount: $

The purpose for requesting
an inventory and appraisal: Please select Insurance GASB #34 Compliance Both Insurance and GASB #34