Please fill out the below information to enroll in the Bay Area DKI Emergency Response Program.
An asterisk (*) denotes mandatory fields for submission.

Referred by:

Your Information:
*Name:
*Email:

New ERP Registration
Updating ERP Profile

About Your Location:
Please provide information about your location.

*Company Name:
*Type of Business:
*Building Address:
*Building City:
*Building State:
*Building Zip:
Website:

*Property Manager:
*Property Manager Phone:
Property Manager Alternate/Cell:
*Property Manager Fax:
*Property Manager Email:

*Number of Locations:

*Type of Location:
Office Building
Condominiums
Warehouse/Storage
Other:

*Total Sq. Footage:
Number of stories:

Special Instructions (i.e. parking entrance, gated community, etc.):

On-Site Contacts In The Event of a Disaster:
Please provide your key contacts that will assist us in accessing property, signing work authorizations, etc. in the event we need to respond to property damage at your facility.

*Primary Contact Name:
*Primary Contact Title:
*Primary Contact Phone:
*Primary Contact Alternate/Cell:

Secondary Contact Name:
Secondary Contact Title:
Secondary Contact Phone:
Secondary Contact Alternate/Cell:

*Are the above authorized to sign work authorization to begin Emergency Services? Yes No

If no, please provide contact information for someone that is authorized to sign:
Authorized Signer Name:
Authorized Signer Title:
Authorized Signer Phone:
Authorized Signer Alternate/Cell:

Insurance Information:
Please provide your insurance information so that, in the event of a disaster, Bay Area DKI can work with your insurance agent.

Deductible:
Per building? Yes No

Risk Manager:
Risk Manager Phone:
Risk Manager Email:

*Insurance Carrier:
Insurance Broker/Agent:
Insurance Broker/Agent Phone:

Please be sure all required fields are filled in before hitting "Submit". Please click "Submit" only once.