Fillable EV CPL Supplemental Application (Kinsale Insurance)

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EV CPL Supplemental Application (Kinsale Insurance)

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Page 1 of 7
COMBINED CONTRACTOR’S POLLUTION LIABILITY APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS. ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS AND SIGN APPLICATION. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED FOR COVERAGE.
If not applicable, indicate N/A.
1)
Named Insured:
Brokerage/Broker:
Agency/Agent:
Renewal?
Yes No
Policy Number:
Effective Date:
Website:
2) Current Carrier Information:
Coverage
Carrier
Limit of
Insurance
Deductible
Premium
Retroactive
Date
General Liability
Contractors Pollution
Liability
Pollution Legal Liability
Non-Owned Disposal
Sites
Transportation Pollution
Professional Liability
(E&O)
Mold Liability
Please attach copies of the following:
a) Currently valued five year loss runs, including claim detail for all losses open or exceeding $15,000
b) Applicant’s product brochures or catalog if a website is not available
3) Mailing Address:
City: State: Zip Code:
4) Your premise address (if different from above):
City: State: Zip Code:
GENERAL INFORMATION
Page 2 of 7
5) Requested Coverages
Contractor’s Pollution Liability Transportation Pollution Liability
Pollution Legal Liability from a Covered Location Professional Services Liability
Non-Owned Disposal Site Coverage Mold Liability
6) During the past three years, has the applicant had any coverage non renewed, cancelled Yes No
or declined? If yes, explain:
7) Limits Requested: $500,000/$500,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000 Other:
8) Deductible Requested: $1,000 $2,500 $5,000 $10,000 Other: $
9) History and Projections:
Estimated Upcoming Year
Current Year
Prior Year
Gross Annual Receipts
Employee Payroll
Cost of Subcontracted
Work
Number of Employees
10) Are all your subcontractors licensed? Yes No
11) Please list subcontracted services and applicable cost:
12) Is a standard written contract used with clients and subcontractors using a limitation Yes No
of liability clause and hold harmless clause? (Please provide a copy.)
13) Are subcontractors required to have pollution liability insurance? Yes No
If required by trade only, please identify trades:
14) Does your firm collect certificates of insurance from all subcontractors? Yes No
How long do you retain those certificates?
15) Are you named as an additional insured on all subcontractors’ policies? Yes No
16) How often and under what circumstances will you use uninsured subcontractors?
17) What general liability limits do you require your subcontractors to carry?
18) Does your contract require that your subcontractors have a Waiver of Subrogation Yes No
endorsement in your favor on their General Liability and Worker’s Compensation policies?
SUBCONTRACTING INFORMATION
Page 3 of 7
19) Indicate which environmental services apply and the total gross receipts for the next 12 months. (Including subcontracted
work)
Expected Revenue
Expected Revenue
Drilling Services (not oil/gas)
Analytical Laboratories
Asbestos Remediation
Mold investigation/consultant
Lead Remediation
Civil Engineering
Mold Remediation
Environmental Compliance
Bio Remediation
Environmental Sampling
Underground Tank Installation
Environmental Impact Studies
Underground Tank Removal
Environmental Permitting
Above Ground Tank Installation
Expert Witness Services
Above Ground Tank Removal
Hydrogeology Consulting
Emergency Response
Geotechnical (foundation, soils
etc.)
Hazardous Materials Cleanup
Remedial Investigation
Liquid Waste Remediation
Remedial Design
Dredging
Remediation Oversight
PCB Handling
Field Sampling & Testing
Soil Excavation & Treatment
Project Management
Mobile Incineration
Asbestos Analysis
Wastewater Treatment
Lab Packing
Water extraction/drying
residential
Phase I & II Assessments
Water extraction/drying
commercial
Other:
Other:
20) Indicate which non-environmental services apply and the total gross receipts for the next 12 months. (Including
subcontracted work)
Expected Revenue
Expected Revenue
Airport Runways
Electrical
Blasting
Excavating
Bridge Building
Gas Mains
Carpentry
Insulation
Concrete
Landscaping
Demolition
Maintenance
Drilling
Masonry
Dry Wall
Mechanical
Painting
Steel (Structural)
Plastering
Street/road construction
Plumbing
Supervision only
Roofing
Traffic signals/traffic control
Sewer/water mains
Tunneling
Sheet metal
Other
Steel (ornamental)
Project Management
OPERATIONAL INFORMATION
Page 4 of 7
21) Does your firm have an in-house continuing education/training program? Yes No
If yes, please describe. If no, please describe how your professionals receive
continuing education/training?
22) Does your firm have written health and safety procedures? Yes No
If yes, please provide a copy of the table of contents.
23) Do you provide a watchman or security at job sites? Yes No
24) Does your firm perform work on residential properties? Yes No
If yes, what percentage? %
25) Please describe any operations or services that have been discontinued, sold, or abandoned, or any operations that have
been acquired.
26) Does the applicant own, operate, or lease a treatment, storage, or disposal facility? Yes No
If yes, please provide details.
27) Is the applicant providing any new services not provided last year? Yes No
If yes, please provide details.
28) Does the applicant or any person or organization for whom the applicant is or may be liable Yes No
engage in now or in the past in Design/build activities?
29) If applicable, please submit a copy of company’s lead and asbestos handling licenses.
30) Disposal of Hazardous Materials:
Transported by applicant? Yes No
Transportation by independent hauler? Yes No
Manifested? Yes No
Disposal Forms? Yes No
Drummed/over pack? Yes No
Bagged and labeled? Yes No
Wastes liquid or solid? Liquid Solid
Treatment on site or off site? On site Off site
31) Do you require certificates of insurance from subcontractors as evidence of mold Yes No
coverage?
32) What limits do you require of your subcontractors for mold coverage?
33) Do you have and utilize a written protocol for handling mold reports and complaints? Yes No
34) Do you advise the client that mold problems will reoccur if moisture problems are Yes No
not corrected? Please describe how this is documented.
35) Do you diagnose, correct, or warrant against moisture problems creating mold problems? Yes No
Please provide a copy of the documentation given to the client.
COMPLETE THIS SECTION IF MOLD OR HAZARDOUS MATERIAL ABATEMENT WORK IS PERFORMED OR
CONTEMPLATED
Page 5 of 7
36) Does the firm use a disclaimer or limitation of liability in contracts for work related to Yes No
mold investigation or removal?
37) What percentage of revenues can be attributed to mold/hazardous material abatement at commercial
structures?
38) What percentage of revenues can be attributed to mold/hazardous material abatement at residential
structures?
39) Is surface sampling/testing done before and after remediation? Yes No
Who conducts this and what are their qualifications?
40) Is air quality testing done before and after remediation? Yes No
Who conducts this and what are their qualifications?
41) Are remediation alternatives offered and carefully explained to the client prior to Yes No
remediation being performed? How is this documented?
42) If pollution legal liability is being applied for, please provide location, address, state and zip code for all locations needing
coverage.
Facility Address
Brief Description of Operations
Historical Operations
43) Are all of the locations listed above currently in compliance with federal, state, and Yes No
local environmental regulations? If not, please describe.
44) Are any of these locations currently undergoing corrective action or active remediation, or Yes No
have any locations had corrective action or active remediation performed in the past? If yes, please explain.
45) Have any of these locations received an environmental violation? Yes No
If yes, please provide details.
46) Are there structures on these properties? Yes No
If so, please describe.
47) Have these structures been tested for and found to be free of asbestos, radon, and lead Yes No
paint? If “no”, please explain.
SITE POLLUTION
Page 6 of 7
48) Please describe types of hazardous waste or materials transported.
49) Of the total amount hauled, what percentage of materials are liquid? %
50) Average radius of trip? Miles
51) Vehicle maintenance program in effect? Yes No
52) Does insured own or have insurable interest in hazmat disposal facility? Yes No
53) Please describe any pollution claims that have occurred in the last five years.
54) At the time of signing this application, are you aware of any circumstances that may Yes No
reasonably be expected to give rise to a claim under this policy? If so, please provide
details.
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND
WYOMING APPLICANTS: In some 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, for the purpose of misleading, conceals information concerning any fact material
thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding
the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially
related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit
is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS: 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 denial of insurance benefits.
HAZARDOUS WASTE TRANSPORT/TRANSPORTATION POLLUTION LIABILITY
CLAIMS HISTORY
Page 7 of 7
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value of the claim
for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement is guilty of insurance fraud.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim for
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an application
for insurance or statement of a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit any
material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective date
of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn based
upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application
and made a part of this application.
Applicant: ______________________________________ Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
FEIN #:
Applicant’s Signature: Date:
Agent/Broker Name:
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EV CPL Supplemental Application (Kinsale Insurance)

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Completed 16 July 2020

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