SECTION I GENERAL INFORMATION
Named Insured:
Address:
Telephone Number: Fax Number:
Website: www.
Risk Management Contact: Risk Management’s Phone:
Risk Management’s Email:
Past Fiscal Year Estimated Current Year Projected
Total Gross Annual Revenues $ $ $
Please provide audited financials for the past two (2) years.
1. During the past year, has your company purchased any other companies or been engaged in any type
of merger, acquisition or name change?
Yes No
If yes, please explain:
2. Has your company experienced significant shifts in revenue by services in the past year or do you
anticipate a significant shift in the coming year?
Yes No
If yes, please explain:
3. Has your company started offering any new services or project types in the past year or do you
anticipate adding new services or project types in the coming year?
Yes No
If yes, please explain:
4. Are you aware of any fact or circumstance that could reasonably be expected to result in any project
delay, professional or environmental liability claim, suit, governmental action or notice of incident
against your company or any party to this insurance?
Yes No
Please send submissions to: ESsubmissions@phly.com if revenue is > $5M
Please send submissions to: EASsubmissions@phly.com if revenue is < $5M
CONTRACTOR ENVIRONMENTAL AND PROFESSIONAL COVERAGE (CEPC)
RENEWAL APPLICATION
Contractor Environmental and Professional Coverage
Renewal Application
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SECTION II PROJECT DELIVERY METHODS
1.
Delivery Method
Last Completed Fiscal Year
Estimated Current Fiscal year
Construction Only without any obligations for design or
Construction Management Agency
Payroll:
Construction Values:
Payroll:
Construction Values:
Construction Management Agency holding no design or
construction subcontracts.
Fees:
Construction Values:
Fees:
Construction Values:
Construction Management At Risk- provides consulting
services during preconstruction and self performs or holds
and manages construction subcontracts during
Fees:
Construction Values:
Fees:
Construction Values:
Design/Build with in-house design assume contractual
obligations for design and construction where design is
substantially performed in-house
Fees:
Construction Values:
Fees:
Construction Values:
Design/Build with subcontracted design assume
contractual obligations for design and construction where
design is substantially subcontracted to others
Fees:
Construction Values:
Fees:
Construction Values:
Design Services performed for others with no contractual
obligations for construction or Construction Management
Fees:
Construction Values:
Fees:
Construction Values:
Other (Specify):
Fees:
Construction Values:
Fees:
Construction Values:
Totals:
Fees:
Construction Values:
Fees:
Construction Values:
SECTION III PROJECT TYPE(S)
1.
Category
Percentage
Category
Percentage
Apartments
%
Industrial / Manufacturing
%
Assisted Living and Retirement
%
Marine
%
Single Family Homes and Townhomes
%
Mining, Petroleum or Chemical
%
Commercial Office or Retail
%
Road / Highway
%
Condominiums High Rise
%
Tunnels / Bridges / Mass Transit
%
Environmental
%
Schools: K-12 or University
%
Hospital / Medical Facilities or Offices
%
Water or Waste Water Plants
%
Hotels / Motels
%
Other: (describe)
%
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.
Contractor Environmental and Professional Coverage
Renewal Application
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FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company.
FRAUD NOTICE STATEMENTS
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 AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON,
THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO
PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR FRAUDULENT CLAIM
FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE
IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: 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
.
APPLICABLE IN FLORIDA AND OKLAHOMA: 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 (IN FL, A
PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED
OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT
THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION OR STATEMENT AS PART
OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL
INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH
SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE
OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO
.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS FILES AN
APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME
.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: 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.
APPLICABLE IN PENNSYLVANIA: 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.
APPLICABLE IN VERMONT: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A
CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW
.
APPLICABLE IN NEW YORK: 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 BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
Name (Please Print/Type) Title
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO, OWNER,
PARTNER, DIRECTOR/ OFFICER OR PRINCIPAL OF THE INSURED)
____________________________________________________
Signature Date
Produced By: (Section to be completed by Producer/Broker)
Producer Agency
Address (Street, City, State, Zip)
Resident or Non-Resident Surplus Lines Licensee Information for Applicant’s State of Domicile
SL License State SL License No.
Agency Taxpayer ID or SS Number
Contractor Environmental and Professional Coverage
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