AIG Private Client Group

I am the owner of the residence indicated below, and I have a homeowners insurance policy covering this residence through AIG Private Client Group. I hereby authorize Firebreak Spray Systems, LLC. (hereinafter “FSS") 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, FSS can enter my property at any time during a wildfire in order to apply an emergency treatment. It is FSS’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 FSS, including the treatment, may not prevent damage to my property or residence from wildfires. I also understand that there is no guarantee that FSS will be able to apply the treatment to my property before a wildfire damages my property. I HEREBY WAIVE ANY CLAIM AGAINST FSS 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 FSS ARE “AS IS” AND FSS SPECIFICALLY DISCLAIMS ALL WARRANTIES TO THE SERVICES EXCEPT AS SPECIFICALLY STATED HEREIN. FSS does warrant that any service provided will be done in a workmanlike manner.

I understand that all fees for this emergency service and the treatment will be paid through AIG Private Client Group, and as a policyholder I will not be charged for this service. AIG Private Client Group 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. Other services provided by FSS, such as permanently installed fire mitigation systems, can be purchased directly from FSS by calling:
(800) 899-2409.

* indicates required fields

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 AIG 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:

I’d like to receive a complimentary disaster preparedness assessment to help me determine if I need to better prepare my home and my family for disaster. Please contact me to set up a consultation.
Yes No

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

Name:

Phone:

Insurance agent:

This Authorization Form can be rescinded at any time in writing by sending notice to the below address:
Firebreak Spray Systems, LLC warrants the system as set forth in the Disclaimer and Limitations of Warranties. FIREBREAK SPRAY SYSTEMS, LLC MAKES NO OTHER WARRANTIES OR GAURANTEES, EXPRESS OR IMPLIED, AND SPECIFICALLY DISCLAIMS ALL OTHER WARRANTIES REGARDING THE PRODUCT AND SYSTEMS, INCLUDING ANY IMPLIED WARRANTY OF MERCHANTABILITY OR FITNESS FOR ANY PARTICULAR PURPOSE. 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. IN NO EVENT SHALL FIREBREAK SPRAY SYSTEMS, LLC BE LIABLE FOR INCIDENTAL OR CONSEQUENTAIAL DAMAGES OF ANY KIND RESULTING FROM THE USE OF OR FAILURE OF THE PRODUCT OR SYSTEM.

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