__________________________________________________________________________
Name of Insurance Company to which Application is made (herein called the “Insurer”)
CONTRACTOR ENVIRONMENTAL COVERAGE APPLICATION
SUPPLEMENTAL CLAIM INFORMATION
Submit one form for each claim or incident. If spac
e is insufficient to answer 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 expen
ses incurred/estimate: $
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 de
ductible: $
B. Expenses paid in excess of deductible: $
C. Deductible: $
CEC Supplemental Claim Information
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© 2019 Philadelphia Consolidated Holding Corp.
