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CONTRACTOR ENVIRONMENTAL COVERAGE (CEC) WRAP APPLICATION OWNER CONTROLLED (Philadelphia Insurance Companies)

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CONTRACTOR ENVIRONMENTAL COVERAGE (CEC) WRAP APPLICATION
OWNER CONTROLLED INSURANCE PROGRAM (OCIP)
CONTRACTOR CONTROLLED INSURANCE PROGRAM (CCIP)
INSTRUCTIONS
● Please answer all questions completely. If any question does not apply, please check “no” or state “N/A”.
● If additional space is required, please provide on separate sheet and reference the section and question number.
● This form must be signed and dated by an owner, partner, director / officer or principal of the Applicant.
SUBMISSION REQUIREMENTS
1.
Complete copy of the Project Contract and Scope of Work (including all exhibits, drawings and specifications,
and any special conditions sections.) If no contract has been finalized, provide the bid documents, scope of work,
etc.
2.
Copies of all Environmental Studies, reports, audits and / or remediation work plans prepared or issued for the
project, if applicable.
3.
Copies of Contracts between lead contractors and / or owner and all sub-contractors working on this project.
4.
Financial Statements for the Named Insured (Lead Contractor or Owner), or for other member or equity partner on
the project, as applicable and relevant. (Income Statement and Balance Sheet for the last two completed fiscal
years).
5.
Three (3) years of currently valued Loss Runs for any GL, CPL and Professional Liability policies held by the
Lead Contractor. Also, provide loss specifics for any pollution contamination incidents at other projects, or at other
properties developed or operated by the Owner, as applicable.
SECTION I – GENERAL INFORMATION
Applicant Name:
Date Completed:
Mailing Address:
City:
Zip:
Website: www.
Requested Policy Structure:
OCIP
CCIP
Project (Non-wrap up)
Risk Management Contact:
Risk Management’s Phone:
Risk Management Email:
SECTION II – PROJECT INFORMATION
1.
Project Name:
2.
Contract Number:
3.
Project Location:
4.
Construction Start-up Date:
Date of Final Completion:
5.
Estimated TOTAL CONSTRUCTION COST (TCC) for the Project: $
6. Project description – Nature of construction or contracting operations to be performed (or attach SOW as
necessary):
Contractor Environmental Coverage (CEC)
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7.
Site description (include acreage, significant site features, body of water and immediate
surrounding areas):
8. Project 'etails
# Units # Of Buildings # Of Stories Construction Type**
Single family dwellings*
Multi-tenant residential*
Commercial / Retail*
Hospitality
Industrial
Medical
Other:
* Additional information will be required
**(Example: stick-built frame, wood over concrete podium, concrete and steel)
9. Will construction involve the use of Exterior Insulation Finish System (EIFS)? Yes No
10. Was / is the project site previously developed? Yes No
Please describe: (Include details on any previous site improvements which will remain a part of the
final project)
11. Is there a demolition component to this project? Yes No
Please describe:
12. Will the project include any pollution conditions clean-up or remediation activities? Yes No
Please describe:
13. Are there any environmental reports for the project site or are any environmental assessments
planned?
Yes No
If yes, identify the environmental reports conducted or planned:
14. Is this a Superfund National Priorities list or DOD / DOE site? Yes No
15. Are there exposures to hillsides, slopes, landfills or other subsidence issues? Yes No
16. Are there any exposures to wetlands, waterways, or other environmentally sensitive areas? Yes No
17. Are there any exposures to pipelines, ASTs or USTs previously at the site, or to be developed? Yes No
18. Will there be an environmental consultant managing environmental affairs for this project? Yes No
19. Which of the following risk control or operational procedures will be implemented during the project:
Project Specific Health and Safety Plan Excavation and Underground Utility Risk Plan
Erosion Prevention and Sediment Control Storm Water Pollution Prevention and Control Plan
Dust Control and Prevention Plan Soils Management Plan
Vapor Barrier or Radon Mitigation Cap or other Engineered Barrier
20. Does any portion of your work involve excavation, grading, or otherwise involve placement or
compaction of soil or involve subsurface conditions?
Yes
No
If yes, provide full details and documents.
Contractor Environmental Coverage (CEC)
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SECTION III – ENVIRONMENTAL CONTRACTING TO BE PERFORMED
1.
Indicate projected construction cost, or % of TCC, for each of the following classes of operations (as applicable):
Contracting Operations
Estimated Construction Cost or % of TCC
Clean-up of Pollution in Soil or Groundwater
Asbestos and / or Lead Based Paint Abatement
UST Installation or Removal
Hauling and Disposal of Haz-Mats or Contaminated Material
Facility Decommissioning or Decontamination
SECTION IV – CONSTRUCTION QUALITY CONTROL
1.
Will a quality control program be implemented to monitor all construction activities on the project?
Yes
No
a.
Who is responsible for managing the program:
b.
Briefly describe the program and / or attach a copy of the program to this application:
2.
Will a written site inspection program be implemented on the project?
Yes
No
a.
When will the inspections be performed:
b.
Will surprise inspections be conducted:
c.
Who conducts the inspections:
d.
Will there be established criteria for required follow-up:
3.
Will independent inspection / assessments be performed?
Yes
No
a.
Who is providing the service:
b.
Briefly describe the scope of their services (or attach a copy of their contract to this
application):
c.
What percentage of units are to be inspected and how often: %
SECTION V – PROJECT TEAM BACKGROUND / EXPERIENCE
1.
Project Owner / Developer / Sponsor
Name of Owner / Developer / Sponsor:
Describe past construction experience of the Owner / Developer / Sponsor with similar projects:
2.
Project General or Primary Contractor
Name of General or Primary Contractor:
Number of years constructing similar projects:
Provide details of past similar construction experience (i.e. the number and types of similar
structures built):
3.
Project Environmental Contractor / Engineer N/A
Name of environmental contractor or firm:
Number of years in business:
Provide details of past environmental experience on similar projects (i.e. the number of years’
experience with the specific types of environmental issues facing this project):
Contractor Environmental Coverage (CEC)
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SECTION VI – NAMED INSUREDS AND ADDITIONAL INSUREDS TO BE LISTED
Name of Person or Organization
Interest in the Policy
(i.e. Project Owner, Project Sponsor, General
Contractor, Environmental Contractor, etc.
Name Insured (NI) /
Additional Insured
NI
Add’l Insured
NI
Add’l Insured
NI
Add’l Insured
NI
Add’l Insured
NI
Add’l Insured
SECTION VII – COVERAGE REQUESTED
1. Contractors Pollution Liability: Occurrence Claims Made
2. Limits of Liability: Per Contamination Incident: $ Aggregate Limit: $
3. Deductible / SIR: $
4. Policy Term:
From: To:
5. Completed Operations Extension / Extended Reporting Period requested (number of years):
6. Mold / Microbial matter coverage requested:
†
Yes
No
7. Waste Disposal / Non-Owned Disposal site coverage requested:
Yes
No
8. Transportation Pollution Liability (TPL) coverage requested:
Yes
No
MOLD / MICROBIAL MATTER COVERAGE
a. For the immediate past 3 year period, have there been any known incidents, claims or other
circumstances concerning the existence, growth or presence of microbial matter or mold in
any of the leading contractor’s previous work or at this project?
Yes
No
If yes, please describe:
b. Were any significant design or material selection decisions made to prevent mold
development or growth for the contemplated project?
Yes
No
If yes, please describe:
c. Will there be a Standard Operating Procedure (SOP) and / or written Quality Assurance Plan
designed to identify, prevent and respond to water intrusion and mold in the construction
process?
Yes
No
If yes, please attach.
d. Will building materials be inspected upon delivery for pre-existing mold contamination?
Yes
No
SECTION VIII – CLAIM HISTORY
1.
Is the Applicant aware of any act, error, omission, fact , incident, unresolved dispute, accident,
situation or other circumstance that may reasonably result in a claim being made against them or
any other person or entity for which coverage is being sought as respects this project?
Yes
No
If yes, provide full details:
The policy for which the Applicant is applying for will not cover: (i) any circumstance or incidents that the
Application was aware of prior to the policy inception date; or (ii) any incidents or circumstance identified
or that should have been identified in response to this question 1.
2. Has the Applicant or any other party to the proposed insurance ever been subject to disciplinary
action as a result of their professional services or contracting services?
Yes
No
If yes, give full details:
Contractor Environmental Coverage (CEC)
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3.
Within the immediate past three (3) years have any claims been made or legal actions been
brought against the Applicant or other party to the proposed insurance?
Yes
No
If yes, provide full details.
4.
Within the immediate past three (3) years, has the Applicant reported any claims or circumstances
to any other liability insurer?
Yes
No
If yes, provide full details and loss runs.
If there have been any incidents, claims or other circumstances concerning the existence, growth or
presence of microbial matter or mold in that three (3) year period, please provide details regarding
claimant, nature of claim, amount paid or estimated to be paid, and final disposition or current status.
No application will be accepted unless signed by the Applicant
The Applicant represents and warrants on its behalf and on behalf of each and every partner, officer, director,
member, stockholder, and employee that the individual signing this application has authority to do so on behalf of
and with the intent to bind the Applicant and that after reasonable investigation the information submitted in
connection with this Application, whether attached hereto or in any supplement, as well as all answers to the
questions on this application are complete, true and correct. Any person who, knowingly and with the 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. Breach of this provision can result in the forfeiture of any policy issued on reliance upon this
application from policy inception.
Application Addendum
Philadelphia Insurance Companies or its authorized representatives are hereby authorized to
conduct such inquiries as necessary to verify all information.
Contractor Environmental Coverage (CEC)
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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 Coverage (CEC)
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04/2020
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Completed 7 November 2020

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