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)
Page 1 of 3
© 2019 Philadelphia Consolidated Holding Corp.
