This form is to be utilized in accordance with NCGS 143-143.7 Elevator safety requirements for certain residential rental accommodations

“Upon installation of a door baffle, door space guard, door, or gate meeting the requirements of the law, the landlord shall provide the Commissioner of Insurance with one of the following:

(1) A statement signed by a professional elevator installer certifying installation of the door baffle, door space guard, door, or gate meeting the requirements of the law.

(2) A receipt for purchase of the door baffle, door space guard, door, or gate meeting the requirements of the law, a signed statement by the landlord stating the date of installation, and photographs depicting the door baffle, door space guard, door, or gate as installed.”

Property Owner Information

First Name

Last Name

Phone Number

Email Address

Elevator/Hoist Property Information

Property Address

Number of elevators and hoists

Supporting Documents

Attach Supporting Documents

Type of Supporting Documents you are Submitting:

A statement signed by a professional elevator installer certifying installation of the door baffle, door space guard, door, or gate meeting the requirements of the law.

A receipt for purchase of the door baffle, door space guard, door, or gate meeting the requirements of the law, a signed statement by the landlord stating the date of installation, and photographs depicting the door baffle, door space guard, door, or gate as installed.

Questions?
Please contact ReBecca Latham at 919-647-0013 or elevator.safety@ncdoi.gov

Owner Name

date

Your session has timed out.