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CNA CNA PARAMOUNT <br />Policyholder Notice - Countrywide <br />REQUEST FOR JURISDICTIONAL INSPECTION <br />Insured Name: <br />Facility/Location Name: <br />Policy Number: Policy Term: <br />Contact Person & Title: <br />Contact Phone Number(s)—Office: Cell: <br />Contact Email Address: <br />Location Address' <br />City <br />State <br />Zip <br />1. <br />2. <br />3. <br />Equipment Type2,14 <br />Boiler Pressure Vessel <br />Registration <br />Number <br />State # <br />Certificate Expiration <br />Date <br />Completed By (Name & Date): <br />Telephone #/Email Address: <br />BY EMAIL: EBinspections(cDcna.com (please scan the completed form and attach) <br />BY MAIL: BY FAX: 609-524-3649 <br />CNA Equipment Breakdown Risk Control <br />184 Liberty Corner Road <br />4`h Floor, Suite 402 <br />Warren, NJ 07059 BY PHONE: call 866-262-0540 — press "4" <br />'If multiple objects and/or multiple locations, please list all required information on separate page(s). <br />2Boiler is defined as an enclosed vessel heated by fuel or electricity to produce steam or hot water. <br />'Pressure Vessel is defined as an enclosed vessel (tank) greater than 6 cubic feet (18 inches x 40 inches) to store liquid <br />or gas under pressure for use when needed. <br />'LPG (ex: propane, propylene, butane & butylenes) Tank with vapor pressures not exceeding that allowed for commercial <br />propane. California requirement only. <br />CNA62823XX (07-2017) Copyright CNA All Rights Reserved. <br />�oRaN <br />} z <br />a <br />RiskMmRgemerdDivisinn <br />REVIEWED & APPROVED BY.- <br />p PZ. VSA44a <br />Risk Management Analyst <br />