Fillable ENVIRONMENTAL IMPAIRMENT LIABILITY INSURANCE APPLICATION (Risk Placement Services, Inc.)

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ENVIRONMENTAL IMPAIRMENT LIABILITY INSURANCE APPLICATION (Risk Placement Services, Inc.)

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ENVIRONMENTAL IMPAIRMENT LIABILITY INSURANCE APPLICATION Page 1 of 4
ENVIRONMENTAL IMPAIRMENT LIABILITY
INSURANCE APPLICATION
PLEASE ANSWER ALL QUESTIONS COMPLETELY
NOTICE: If a policy is issued, the limit of liability available to pay judgments for settlements shall be reduced by amounts
incurred for legal defense. Further note that amounts incurred for legal defense shall be applied against the deductible or
retention amount.
A. APPLICANT INFORMATION
Applicant: Date:
Address:
City: State:
Zip Code:
Phone:
Company is an: Individual Partnership Corporation Joint Venture Other .
(please describe)
B. REQUESTED COVERAGE
1. Coverage Requested:
New Business Renewal
2. Proposed Effective Date:
Proposed Retroa
ctive Date:
Third Party Pollution Liability
On-Site Cleanup
4. Other Coverages and Endorsements:
5. Have you ever carried site pollution coverage before? Yes No
If so, please provide coverage dates: -
3. Limits Of Liability/Deductible:
Limits Requested:
Deductible Requ
ested:
-- or --
SIR requested:
C. HISTORY OF COMPANY
1. Date Company Was Established:
2. Have there been any acquisitions,
consolidations, dissolutions, and/or
mergers?
Yes
No
If yes, please explain:
3. Does the firm have: Subsidiaries
A parent company
Other related entities
If so, please explain:
4. Do you share employees? Yes
No
If yes, please explain:
D. PRIOR CARRIER LIABILITY INFORMATION
1. Coverage Form 2. Carrier 3. Receipts 4. Limit of Liability 5. Deductible 6. Policy Type 7. Rate 8. Premium
1.
2.
3.
9. Has any policy or coverage been declined, cancelled and/or non-renewed during the prior three years?
Yes (If yes, please explain):
No
ENVIRONMENTAL IMPAIRMENT LIABILITY INSURANCE APPLICATION Page 2 of 4
ALL APPLICANTS MUST SUBMIT THE FOLLOWING INFORMATION IN ADDITION TO THE APPLICATION:
1. Copies of all environmental audit or assessment reports that have been conducted within the past three years.
2. Most recent income statement and balance sheet.
3. Five years of valued loss runs, if applicable.
E. DESCRIPTION – Please complete the following for all locations you wish to be covered.
LOCATION ACREAGE DESCRIPTION OF CURRENT OPERATIONS
LENGTH OF
OPERATIONS
1.
2.
3.
4.
5.
6.
F. Describe current operations:
G. List all structures on the property:
H. Provide a list of additional occupants on this property (owned or leased):
I. Provide site history including all past land use and the time period for each operation:
J. Identify any past storage or disposal practices at the site including any on site disposal:
K. Environmental Information:
1. Has any building structure been tested for lead-based paint, asbestos or radon?
Yes No
2. Has fill material ever been used at the property?
Yes No
3. Are there any dry wells, septic systems, leach field or oil/water separators at the property?
Yes No
4. Has any remediation or monitoring of soil or groundwater ever taken place at the property?
Yes No
5. Has there ever been any testing of soil, groundwater, surface water or air at the property?
Yes No
6. Does the use of the property require any environmental permits?
Yes No
7. Are there any plans to conduct any testing of soil, groundwater or surface water at the property?
Yes No
L. Hazardous Waste and Materials
Does t
his property generate, handle, store or dispose of any hazardous waste or materials?
Yes No
ENVIRONMENTAL IMPAIRMENT LIABILITY INSURANCE APPLICATION Page 3 of 4
If yes, please complete the following:
1. Type of hazardous waste or materials:
2. Describe the on site storage practices and storage areas:
3. Describe the disposal method used:
M. Storage Tanks
Does t
his property presently have any storage tanks?
Yes No
If yes, please complete the following:
a. Explain the tank inventory control program:
AST/UST Tank No. Tank Construction
Tank Size
(Gals.)
Age
Date of
Installation
Contents
Secondary
Containment
Date & Results
of Last Testing
1.
2.
3.
4.
5.
6.
7.
8.
N. Property Location
1.
Provide a des
cription of adjacent properties:
a. North:
b. South
c. East:
d. West:
2. Identify nearby surface water bodies including approximate distances (i.e. streams, lakes, wetlands):
3. Are there any protected environments in the area or sensitive receptors (parks, wildlife preserves, etc.) or school areas
where children may frequent:
Yes No
If yes, please describe:
4. Identify any surface or groundwater uses in the area (drinking wells, etc.):
5. Is public water and sewer available: Yes No
6. Provide information on any mandated or voluntary monitoring performed at considered location (i.e. groundwater
monitoring wells, NPDES, CAA, etc.):
O. Waste
Does your
facility treat, process, separate or store any type of waste (i.e. liquid, solid, wastewater)?
Yes No
If yes, please complete the following:
1. Type of Waste:
2. Describe the waste treatment operation:
3. Maximum amount of waste processed per day:
4. Maximum amount of waste stored at any one time:
5. Daily operating procedures in place?
Yes No
6. Are emergency procedures in place?
Yes No
7. Identify effluent discharge points for wastewater and storm water:
P. Landfill
Do you ha
ve a landfill on site?
Yes No
If yes, please complete the following:
1. Acreage:
Active Landfill:
Closed Landfill: Vacant Land:
2. Type of waste collected:
ENVIRONMENTAL IMPAIRMENT LIABILITY INSURANCE APPLICATION Page 4 of 4
3. Is the landfill lined?
Yes No
Type of liner:
Material:
Thickness:
4. Is there a leachate collection system in place?
Yes No
Amount of leachate produced annually?
5. Number of active groundwater monitoring
wells in place?
Total Up gradient Down gradient
6. Are daily operating procedures in place?
Yes No
7. Are emergency procedures in place?
Yes No
Q. Violations
1. Have you during the last five years received any violations regarding any standard or law relating to the
release of a substance from the location(s) into sewers, rivers, air or onto land?
Yes No
If yes, please provide the details:
2. If yes, have you ever been prosecuted?
Yes No
If yes, please provide the details:
R. Claims
1. Please describe any pollution claims which have occurred during the last five years, (if none, please state so):
2. At the time of signing this application are you aware of any circumstances that may reasonably be expected
to give rise to a claim under this policy?
Yes No
If yes, please provide the details:
FRAU
D WARNING: APPLICABLE TO ALL STATES
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 also be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
WARRANTY STATEMENT
The undersigned authorized officer of the applicant declares that the statements set forth herein are true. The undersigned
authorized officer agrees that if the information supplied on the application changes between the date of the application and
the effective date of the insurance, he/she (undersigned) will immediately notify the insurer of such changes, and the insurer
may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. Signing of this
application does not bind the applicant or the insurer to complete the insurance.
Notice to applicants: 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 fact material thereto, commits a fraudulent insurance act, which is a crime.
Signature:
Print Name:
Title:
Date:
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Completed 30 July 2020

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