Fillable CONTRACTOR ENVIRONMENTAL AND PROFESSIONAL COVERAGE APPLICATION SUPPLEMENTAL CLAIM (Philadelphia Insurance Companies)

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CONTRACTOR ENVIRONMENTAL AND PROFESSIONAL COVERAGE APPLICATION SUPPLEMENTAL CLAIM (Philadelphia Insurance Companies)

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PI-EVCP-003 (09/09)
__________________________________________________________________________
Name of Insurance Company to which Application is made (herein called the “Insurer”)
CONTRACTOR ENVIRONMENTAL AND PROFESSIONAL COVERAGE
APPLICATION
SUPPLEMENTAL CLAIM INFORMATION
Submit one form for each claim or incident. If space is insufficient to a
nswer any question
completely, please use the Additional Information page attached to this application.
1. Full name of the Applicant Firm:
2. Full name of the firm which reported the claim (if different from above):
3. Full name of the claimant:
4. Indicate whether: Claim / Suit Incident / Potential claim Remediation Expense
5. Date / Period of pollution release or incident that led to claim:
6. Date the claim was reported to the insurance carrier:
7. Other parties against which this claim is made:
8. This claim is: OPEN CLOSED
9. If CLOSED, indicate the date closed:
10. Please complete the following:
If claim is still open:
A. Remediation expenses incurred/es
timate: $
B. Claimants settlement demand: $
C. Defendant’s offer for settlement: $
D. Insurance company’s loss reserve: $
E. Deductible: $
F. Total loss and expenses paid to date: $
If claim is closed:
A. Loss paid in excess of deductible: $
B. Expense
s paid in excess of deductible: $
CEPC Supplemental Claim Form
Page 1 of 3
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
Clear Application
Print Application
PI-EVCP-003 (09/09)
C. Deductible:
$
D. Settlement reached via: Court judgment
Formal mediation / Arbitration proceeding
Out of court settlement
E. Type of remediation: Voluntary Program
Formal mediation / Arbitration proceeding
Regulatory Settlement
Note: If information is not available, please provide a copy of the suit papers.
11.
Name of Insurance Company:
12. Claim number:
13. Description of claim / incident:
A. Provide a full description of the engagement, the events leading up to the claim, allegation(s)
asserted against your firm and the current status of the matter. Please indicate if the claimant was
your client. If no, fully explain claimant’s relationship to client:
B. Was an engagement letter used? Yes No
C. What action has your firm taken to prevent a recurrence of such a claim in the future?
CEPC Supplemental Claim Form
Page 2 of 3
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
Clear Application
Print Application
PI-EVCP-003 (09/09)
D. Did this incident or clai
m follow or result from an action to collect fees? Yes No
I understand that the information submitted herein becomes a part of my Philadelphia Insurance
Companies Contractors Environmental and Professional Coverage application and is subject to
the same conditions as stated on the application.
Name (Please Print) Title (Must be Principal Partner or Officer)
__________________________________________
Signature
Date
ADDITIONAL INFORMATION
This section may be used to provide additional information to any question on this application.
Please identify the question number to which you are referring.
_________________________________________________
Signature
Date
CEPC Supplemental Claim Form
Page 3 of 3
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
Clear Application
Print Application
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CONTRACTOR ENVIRONMENTAL AND PROFESSIONAL COVERAGE APPLICATION SUPPLEMENTAL CLAIM (Philadelphia Insurance Companies)

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Completed 7 November 2020

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