Gas Action Plan submission

Personal information

Incident/Claim Number

Name of Occupant

Address

Phone number Email address

Property details

Number of occupants

Special Requirements in case of evacuation (optional)

Details of any alternative accommodation (optional)

Approximate year of construction

Property type

Suspended timber floors

Concrete floors

UPVC windows and doors

Cellar/basement

Monitors and Alarms

GFM 406 alarm installed Serial number if known

Carbon Dioxide alarm installed Serial number if known

Carbon Monoxide alarm installed Serial number if known

Methane alarm installed Serial number if known

Alarm location

Photo of the monitor/alarm location (if known) Description of location / further notes

Have the occupants been informed how the equipment installed at the property operates and what to do in the event of an alarm/emergency?

Agreement

This is to certify that the above equipment has been installed in the above mentioned property and that the occupier has read and understood the information sheet provided.