ARC FLASH HAZARD ANALYSIS QUOTE FORM

COMPANY INFORMATION

Company: Date:
Mailing Address:
City, State & Zip:
Phone: Fax:
Website:

COMPANY CONTACTS

Name: Name:
Title: Title:
Phone: Phone:
Email: Email:

FACILITY DESCRIPTION

Type of facility: Facility age:

Total square ft. under roof: How much is warehouse?
Number of utility feeds to your facility:
Number of overhead busducts and busplugs: /
Number of substations: Number of machine panels:
Is facility predominately fused or circuit breaker?
Number of panelboards / switchboards (100A or greater):
Number of Motor Control Centers (MCCs):
Will you provide an updated / current One-Line Diagram of your facility?
Will you provide the data for the hazard analysis or do you desire that we collect data on-site?
Is this project budgeted and scheduled for this year?

ELECTRICAL SAFETY ARC FLASH HAZARD TRAINING

Do you desire electrical safety training? If yes, how many will attend?
How many sessions will you need?

ELECTRICAL SAFETY PROGRAM

Are you interested in a professional review of your electrical safety program?

Do you desire assistance developing an electrical safety program?

ADDITIONAL INFORMATION

HERZIG ENGINEERING
11108 N. Oak Street Trafficway, Suite 104 Phone: 816-734-8300
Kansas City, Missouri 64155-3636 Fax: 816-734-8493
Please complete as much of the form as possible, but don't allow a particular item to prevent you from sending the form to us.
Please e-mail completed form to: info@bobherzig.com