Name of Insurance Company to which Application is made (herein called the “Insurer”)
CONTRACTOR ENVIRONMENTAL COVERAGE
SM
APPLICATION
SUPPLEMENTAL MOLD CLAIM INFORMATION
Submit one form for each claim or incident. If space is insuffici
ent 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 mold incident that led to claim:
6. Date the claim was reported to the insurance carrie
r:
7.
Indicate whether: Claim Covered Denied Self Insured
8. Other parties against which this claim is made:
9.
This
claim is: Open Closed
10. If CLOSED, indicate the date closed:
11.
Please complete the followi
ng:
If claim is still open:
a. Remediation expenses
incurred/Estimate: $
b.
Claimant’s 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. Remediation expenses incurred: $
b. Loss paid in excess of deductible: $
c. Expenses paid in excess of deductible: $
d. Deductible: $
e.
Settlement reach
ed via:
Court Judgment Formal mediation/Arbitration proceeding Out of court settlement
CEC Supplemental Mold Claim
Information (06/10)
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© 2019 Philadelphia Consolidated Holding Corp.
08/2019
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f. 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.
12.
Name of Insurance compan
y:
13.
Claim
nu
mber:
14. Description of claim / incident:
a. Provide a full description of the engagement, the events leading up to the claim,
allegation 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 or contract used? Yes No
c. What action has your firm taken to prevent a recurrence of such a claim in the
future?
d.
Did this incident or claim 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 Coverage
sm
application and is subject to the same conditions as
stated on the application.
Name (Please Print/Type)
Title (MUST BE SIGNED BY A PRINCIPAL PARTNER OR OFFICER)
_______________________________________
Signature Date
CEC Supplemental Mold Claim
Information (06/10)
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© 2019 Philadelphia Consolidated Holding Corp.
08/2019
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ADDITIONAL INFORMATION
This page 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
CEC Supplemental Mold Claim
Information (06/10)
Page 3 of 3
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
Clear Application
Print Application