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ApplicationGolfPremisesEnvironmentalCoverage36-10840 - Application - Golf Premises Environmental Coverage _PEC_

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Premises Environmental Coverage Application 11/2009
Page 1 of 6
GOLF – COUNTRY CLUBS
PREMISES ENVIRONMENTAL COVERAGE (PEC) APPLICATION
INSTRUCTIONS:
1. If additional space is required to complete an answer, please provide supporting information on
your firm’s letterhead and reference the application question number of the sheet.
2. This form must be signed and dated by an owner, partner, director/officer or principal of the
Applicant.
SUBMISSION REQUIREMENTS
•
Environmental permits or licenses such as NPDES, sewer discharge or treatment permit, hazardous
waste or materials storage permit or storage tank permit
•
Inventory list/quantity used of herbicides, pesticides, fertilizers, chemicals or hazardous materials
•
Pesticide applicator licenses
•
Most recent results of petroleum tank tightness tests, leak detection/inventory monitoring and control
systems
•
Any environmental audits or site assessments
•
Copy of expiring environmental policy
Section I – GENERAL INFORMATION
Club Name: Website:
Business Address:
Telephone Number: Fax Number:
Number of Members
:
Number of Holes:
Name / Contact Information of Enviro
nmental Compliance Office Manager:
Address of the location(s) for which you are seeking coverage:
Other Insure
ds to be listed on the policy and relationship to th
e Named Insured:
Other Insureds Relationship to Insured/Operations
Do you have a PGA Professional on staff? Yes No
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Premises Environmental Coverage Application 11/2009
Page 2 of 6
Coverage Request:
Limits and Deductible: (Please put a check next to each option you would like to see.)
DEDUCTIBLE
EACH INCIDENT LIMIT TOTAL POLICY LIMIT POLICY TERM
$5,000 $500,000 $500,000 1 Year
$10,000 $1,000,000 $1,000,000 2 Year
$25,000 $2,000,000 $2,000,000
Other:
$ Other:$ Other:$
Other:
Remediation Expense from Contamination Off-site
Third Party Claims for Bodily Injury and Property Damage (On-site and Off-Site)
Storage Tank Coverage
Waste Disposal Liability
Mold Coverage* - Please Complete Separate Indoor Air Quality and Mold Supplemental Application
Section II – PREMISES OPERATIONS
1. Club Services:
Beauty Shop Stables Pool / Hot Tub Child Care
Hunting / Skeet Ranges / Trap Ranges Hotel / Guest Quarters Marina / Watercraft
2.
Golf Carts fueled by: Propane Gas
Electric
3.
Are cart / mobile equipment batteries stored in dedicated area designed for storage of batteries?
Yes No
4. Is there any surface water on your property? Yes No
5. If yes, what kind (lined pond, intermittent stream, river, etc.)?
6. Are there any potable water wells on the site? Yes No
If yes, is water tested annually? Yes No
Do the results meet federal, state, and local standards? Yes No
7. Is there any third party drinking water wells located within a ½ mile of your location? Yes No
8. Do you have any environmental permits or licenses such as NPDES, sewer discharge or treatment
permit, hazardous waste or materials storage permits, storage tank permit? Yes
No
9. Sewage is treated by: septic system on-site waste water treatment plant municipal sewer system
10. For on-site septic or waste water treatment plant only:
a. The system discharge to:
Septic tank Leach field Spray field Aeration pond
Stream Pond Municipal sewer system Other:
b. Is there any piping connecting to areas storing hazardous substances? Yes No
c. Do you process waste water for parties other than the golf club? Yes No
If yes, who and what is the annual volume?
Retroactive Date:
Please check the box for each coverage you would like:
Remediation Expense from Contamination On-site
3 Year
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Premises Environmental Coverage Application 11/2009
Page 3 of 6
11. Chemical Usage
a. Do you have certified and/or licensed pesticide / herbicide applicators on staff? Yes No
b. Does the club apply pesticides, herbicides, or fertilizers to its golf course grounds or is that
service provided by a contractor?
If contracted out, does the club obtain certificates of insurance confirming pollution liability
coverage from all contractors? Yes
No
c. Chemical Storage:
i. Do you have complete and reconcilable inventory records kept for all chemicals? Yes No
ii. Do you have a dedicated storage room or building for hazardous materials? Yes No
iii. Does this area have floor drains? Yes No
iv. Does this area have secondary containment? Yes No
v. Do you display Material Safety Data Sheets for all hazardous substances in the storage
area?
Yes
No
vi. Do you have standard operating procedures in the event of a spill? Yes No
vii. Do you have personnel trained in spill response and spill response equipment in the
event of a spill?
Yes
No
12. Historic Information:
a. Have any of the following operations ever been conducted within the property grounds?
Automobile servicing Landfill Petroleum storage or distribution
Dry cleaning Recycling Waste treatment or storage
b. Are there any abandoned tanks or equipment at the site? Yes No
If yes, have they been closed in accordance with the regulation? Yes No
c. Do you have any environmental site assessments or questionnaires that have been performed
for the site(s) where you would like coverage? Yes
No
If yes, please attach.
13. Are there any anticipated changes in use or construction at the location during the policy period? Yes No
If yes, please describe:
Section III – STORAGE TANKS
Please utilize the table below to provide information about your storage tanks and attach pictures of the tanks and copies
of any results of tank tightness testing, leak detection or inventory monitoring and control systems.
1. Are all of your tanks in compliance with the applicable regulations? Yes No
If no, please provide details:
Location
and
Tank ID
Number
UST
AST
Size
(gallons)
Age
Construction
(type of
material and
single wall
or double
wall)
Contents
(specify
material)
Leak
Detection
Prevention
Method
(specify
method)
Containment
(ASTs only)
Piping
**see
key
below
Diked: Yes No
Construction:
Diked: Yes No
Construction:
Diked: Yes No
Construction:
Diked: Yes No
Construction:
Diked: Yes No
Construction:
Diked: Yes No
Construction:
Diked: Yes No
Construction:
(UST means underground storage tank. AST means above-ground storage tank.)
**Piping Key: P= pressure flow, S= suction flow, DBW =double wall, SW=single wall, N/A –none
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Premises Environmental Coverage Application 11/2009
Page 4 of 6
Section IV – WASTE MANAGEMENT
TYPE OF WASTE MATERIAL
ESTIMATED
QUANTITY
METHOD OF
TRANSPORATION
DISPOSAL COMPANY / WASTE
SITE (Landfill/Recycling Site)
Household Trash
Vehicle Maintenance Fluids
Hazardous Materials/Waste
Other (Specify):
_____per
Month
Quarter
Year
Own vehicles
Third Party Carrier
(Specify):
By:
Household Trash
Vehicle Maintenance Fluids
Hazardous Materials/Waste
Other (Specify):
_____per
Month
Quarter
Year
Own vehicles
Third Party Carrier
(Specify):
By:
Household Trash
Vehicle Maintenance Fluids
Hazardous Materials/Waste
Other (Specify):
_____per
Month
Quarter
Year
Own vehicles
Third Party Carrier
(Specify):
By:
Section V – COVERAGE HISTORY (All Applicants must complete this section)
1. Have you had or do you currently have any environmental insurance in place? Yes No
If yes, provide information below and include a copy of the policy:
Carrier Limit Deductible Policy Term Premium
$ $ $
$ $ $
$ $ $
$ $ $
2. With respect to the above coverage, has any Underwriter refused, canceled, or non-renewed
coverage? (Not applicable in Missouri) If yes, provide details: Yes
No
3. In the past five (5) years:
a. Have you been required to do any remediation at the location for which you are seeking
coverage? If yes, please describe: Yes
No
b. Have there been any reportable discharges or releases of any hazardous substances or
pollutants at or from any locations for which you are seeking coverage? If yes, please describe: Yes
No
c. Have there been any claims made against you resulting from the actual or alleged release of
pollutants at, on, under, or from the site for which you are seeking coverage? Yes
No
If yes, please provide details:
4. Are you aware of any fact or circumstance that could reasonably be expected to result in a claim arising
from a release to the environment from the site for which you are seeking coverage? Yes
No
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Premises Environmental Coverage Application 11/2009
Page 5 of 6
No application will be accepted unless signed by the Applicant
The applicant warrants that all answers to the questions on this application are true and correct. Any person who, knowingly and with intent
to defraud any insurance company or other person, files an application for insurance containing any false information , or conceals for the
purpose of misleading information concerning any facts thereto, commits a fraudulent insurance act, which is a crime.
Application Addendum
Philadelphia Insurance Companies or its authorized representatives is hereby authorized to conduct such inquires as necessary to verify all
information contained in this application. Authorization is also given to obtain a personal credit report on the principal of the company.
FRAUD NOTICE STATEMENTS
NOTICE TO APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR
CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT
INSURANCE ACT WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.”
NOTICE TO ALASKA RESIDENTS APPLICANTS: “A PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE AN
INSURANCE COMPANY FILES A CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE PROSECUTED UNDER
STATE LAW.”
NOTICE TO ARKANSAS RESIDENT APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A
CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.”
NOTICE TO ARIZONA RESIDENTS APPLICANTS: "FOR YOUR PROTECTION ARIZONA LAW REQUIRES THE FOLLOWING STATEMENT TO
APPEAR ON THIS FORM. ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS IS
SUBJECT TO CRIMINAL AND CIVIL PENALTIES."
NOTICE TO COLORADO RESIDENTS APPLICANTS: “IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING
FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE
COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY
OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION
TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR
CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE
COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.”
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: “WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN
INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR
FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS
PROVIDED BY THE APPLICANT.”
NOTICE TO FLORIDA RESIDENTS APPLICANTS: “ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE
ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION
IS GUILTY OF A FELONY OF THE THIRD DEGREE.”
NOTICE TO KENTUCKY APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY “MATERIALLY” FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT
WHICH IS A CRIME.”
NOTICE TO LOUISIANA RESIDENTS APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A
CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.”
NOTICE TO MAINE RESIDENTS APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF MARYLAND APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM
FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR
INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.”
RESIDENTS OF MINNESOTA APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING
A FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS
GUILTY OF INSURANCE FRAUD.”
RESIDENTS OF NEW JERSEY APPLICANTS: “ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN
APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.”
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Premises Environmental Coverage Application 11/2009
Page 6 of 6
RESIDENTS OF NEW MEXICO APPLICANTS: “ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT
OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME
AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.”
RESIDENTS OF NEW YORK APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY
OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO,
COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE
THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.”
RESIDENTS OF OHIO APPLICANTS: “ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A
FRAUD AGAINST ANY INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS
GUILTY OF INSURANCE FRAUD.”
RESIDENTS OF OKLAHOMA APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY
INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING
INFORMATION IS GUILTY OF A FELONY.”
RESIDENTS OF OREGON APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR SOLICIT ANOTHER TO
DEFRAUD AN INSURER: (1) BY SUBMITTING AN APPLICATION, OR (2) BY FILING A CLAIM CONTAINING A FALSE STATEMENT AS TO ANY
MATERIAL FACT, MAY BE VIOLATING STATE LAW.”
RESIDENTS OF PENNSYLVANIA APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE
INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS
A FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.”
RESIDENTS OF TENNESSEE APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION
TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND
DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF TEXAS APPLICANTS: IF A LIFE, HEALTH AND ACCIDENT INSURER PROVIDES A CLAIM FORM FOR A PERSON TO USE TO
MAKE A CLAIM, THAT FORM MUST CONTAIN THE FOLLOWING STATEMENT OR A SUBSTANTIALLY SIMILAR STATEMENT: "ANY PERSON
WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE
SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON."
RESIDENTS OF VIRGINIA APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO
AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES AND
DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF WASHINGTON APPLICANTS: “IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSES OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE
IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.”
RESIDENTS OF WEST VIRGINIA APPLICANTS: "ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A
CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON."
_______________________________________________________
Insured Signature Date
_______________________________________________________
Title
_______________________________________________________
Producer Signature Date
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