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If a slip\fall claim is legally filed against you, please print and fill out this form and  mail* it to us. We will notarize and returned registered mail to you for your defense.

* See our address at the bottom of this page.



State of _____________________                                           , 19___


County of _____________________     S.S.


BE IT ACKNOWLEDGED, that ________________________ representing ____________________, of ________________________ ("Seller"), the undersigned deponent, being of legal age does hereby depose and say under oath as follows (and as may be contained on reverse side or signed addendum sheets):


WHEREAS, _____________________ of ____________________ ("Purchaser"), did purchase from the Seller a horizontal friction treatment, called "pHlurousTraction Treatment" (the initial application), which said pHlurousTraction Treatment has been independently tested and proven, upon proper application, to provide an acceptable coefficient of friction (above .50), as prescribed by Underwriters Laboratory ("UL") and OSHA standards, to prevent slip/falls; and


WHEREAS, the ongoing pHlurous Traction Treatment Cleaner (used after the initial application), when used as directed, has been found, through independent certified tests to maintain a "very safe" average range of (.70 to .87 and above) coefficient of friction under the said UL and OSHA standards ("acceptable coefficient of friction"); and


WHEREAS, upon review of the purchase by the Purchaser, Seller hereby declares and certifies that sufficient pHlurousTraction Treatment Cleaner was purchased by Purchaser to have enabled Purchaser to maintain an acceptable coefficient of friction on the horizontal surface in question, assuming it's application was in accordance with directions supplied by Seller;


NOW, THEREFORE: it is the Sellers position: 1) that an expert witness would be able to substantially duplicate the conditions present at the time of an accident; 2) that the pHlurous Traction Treatment Cleaner will produce an acceptable coefficient of friction, establishing probative value for the Purchaser; 3) That under the established case law of the various jurisdictions in the United States, a finding of an adequate coefficient of friction should be admitted as relevant evidence of the absence of negligence and should increase the Purchaser's  chance of avoiding liability for a slip fall accident; and 4) that Purchaser, as a reasonably prudent person(s), exercised due diligence when selecting pHlurous Traction Treatment and Cleaner as it's horizontal surface safety system and that there is a presumption from the volume of purchased material that the horizontal surface was maintained in a reasonably prudent manner without any evidence of negligence.


Witness by hand this ______ day of ______________________, 199___




by ________________________


Signed in the presence of:


______________________      ______________________

Print Name                                 Print Name


______________________      ______________________

Number              Street               Number            Street


______________________      ______________________

  City       State       Zip                 City       State       Zip                        


(_____)________________      (_____)________________

Phone Number                            Phone Number


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 pHluorus Inc. PO box 95870 South Jordan UT, 84095-0870 1-800-SAV-SLIP

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