Fillable Form 1.: CONTRACTOR ENVIRONMENTAL AND PROFESSIONAL COVERAGE (CEPC) (Philadelphia Insurance Companies)

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Form 1.: CONTRACTOR ENVIRONMENTAL AND PROFESSIONAL COVERAGE (CEPC) (Philadelphia Insurance Companies)

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Name of Company
Relationship to Insured
Services Provided
Revenue
During the past five (5) years, has the Applicant’s company purchased any other companies or been
engaged in any type of merger, acquisition or name change?
Yes
No
If yes, please provide a detailed description:
1.
Please indicate the Applicant’s requested Coverage and Limits of Insurance
Selection
Coverage Parts
Limits
SIR /
Deductible
Retroactive
Date
Occurrence – Contracting Operations
Environmental Liability
$ / $
N/A
Claims Made – Contracting Operations Environmental
Liability
$ / $
Claims Made – Professional Liability
$ / $
Claims Made – Non-Owned Location
$ / $
Occurrence – Non-Owned Location
$ / $
N/A
Claims Made – The Applicant’s Insured Location Liability
$ / $
Protective Loss
$ / $
Rectification/Mitigation
$ / $
Other:
$ / $
Please send submissions to: ESsubmissions@phly.com if revenue is > $5M
Please send submissions to: EASsubmissions@phly.com if revenue is < $5M
CONTRACTOR ENVIRONMENTAL AND PROFESSIONAL COVERAGE
(CEPC) APPLICATION
INSTRUCTIONS
1.
Please answer all questions completely for each coverage that the Applicant applied for. If any question
does not apply, please check ‘no” or state N/A.
2.
If additional space is required to complete an answer, please provide supporting information on the
Applicant’s firm’s letterhead and reference the application question number of the sheet.
3.
Additional information, including but not limited to the following, may be needed for a bindable quote:
• Statement of qualifications, including resumes
• Sample client and subcontractor contract forms
• SF254 or 10 largest Project List
• Copy of the Applicant’s mold prevention protocol, if applicable
• Applicant’s audited financials for the past two (2) years and current interim financials
• Currently valued insurance company loss runs for the current policy period and three (3) years prior
Environmental and Professional liability
• A copy of the fully executed contract with the client (For a project policy only)
SECTION I - GENERAL INFORMATION
Telephone:
Date Company Founded:
E-Mail:
E-Mail:
Applicant/Named Insured:
Address:
Physical Address:
Website:
Principal Contact/ Title:
Risk Management Contact:
Risk Management Cell Phone:
EPA Number(s): (if applicable)
Related entities to be listed on the policy and relationship to the Applicant
Contractor Environmental and
Professional Coverage (CEPC) Application
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© 2020 Philadelphia Consolidated Holding Corp.
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2.
The Applicant’s Staff:
Position
Number of Personnel
Number of Certified Professionals and
Type of Certification
Principals, Officers, Directors
Architects/Engineers
Geologists/Scientists
Industrial Hygienists
Project Managers
Supervisors/Foremen
Fields Personnel
Total Staff:
What professional organizations is the Applicant’s firm or its key personnel members of?
3.
General Project/ Client Information
a.
Revenue
Prior Fiscal Year:
$
Current Fiscal Year:
$
Next Fiscal Year:
$
b.
Has the Applicant’s company experienced significant shifts in revenue by services in the
past two (2) years or anticipate significant shifts in the next two (2) years?
Yes
No
If yes, please provide a detailed description:
c.
What is the geographical extent of services/ operations?
i.
United States:
Canada:
Foreign:
ii.
Provide a list of States and/ or Countries:
iii.
Percentage of services/ operations in Louisiana: %
d.
What percentage of revenue is derived from the Applicant’s largest client? %
Client Name:
(1)
Please provide the following information on the three largest contracts from the past year
Client
Revenue
Services Provided
Current Status
$
$
$
e.
Does the Applicant construct wood frame buildings?
Yes
No
f.
Does the Applicant perform residential work?
Yes
No
g.
Is the Applicant involved with Exterior Insulation Finishing Systems?
Yes
No
If yes, please describe the Applicant’s services.
SECTION II – CONTRACTING OPERATIONS ENVIRONMENTAL LIABILITY COVERAGE
1.
Description of contracting operations, services and work performed by the Applicant’s company:
Contractor Environmental and
Professional Coverage (CEPC) Application
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2.
Please provide the number of vehicles the Applicant operates by type:
Vehicle Type
Number of
units
Cargo or Material Hauled
(indicate if hazardous)
Radius of Operation
Private Passenger
Light Truck
Medium Truck
Hvy/Extra Hvy Truck
Trailers
Other:
3.
Does the Applicant’s company own, operate or lease any type of waste (i.e. construction,
household, or hazardous) recycling, treatment, storage or disposal facility?
Yes
No
If yes, please provide a detailed description:
4.
Contracting Services Revenue Breakdown
(A) + (B) = 100%
Contracting Service
Projected Revenue
Next Twelve (12)
months
(A)
% Work
Retained In-
House
(B)
% Work Subcontracted Out
Contracting Services
General Contracting
$
%
%
Construction Management
$
%
%
Excavation/ Grading
$
%
%
Street/ Road
$
%
%
Heavy Highway/Bridge/ Tunnel
$
%
%
Steel Erection
$
%
%
Pipeline Construction/ Cleaning
$
%
%
Utility – Electric/ Gas/ Cable
$
%
%
Water/ Sewer
$
%
%
HVAC
$
%
%
Mechanical
$
%
%
Electrical
$
%
%
Plumbing
$
%
%
Carpentry
$
%
%
Drywall
$
%
%
Masonry/Concrete
$
%
%
Painting
$
%
%
Roofing/Insulation
$
%
%
Residential Developer /Home Builder
$
%
%
Process Piping
$
%
%
Demolition
$
%
%
Drilling (Type: )
$
%
%
Dredging
$
%
%
Fire Sprinkler
$
%
%
Industrial cleaning
$
%
%
Oil Field/Lease Work
$
%
%
Marine Construction and Services
$
%
%
Stone/ Metal Restoration
$
%
%
Fire/ Water Restoration Contractor
$
%
%
Other (Specify):
$
%
%
Environmental Contracting
Soil Excavation
$
%
%
Groundwater Recovery and Treatment
$
%
%
In-Situ Soil or Groundwater Treatment
$
%
%
Emergency Spill Response
$
%
%
Barrier or Liner Installation
$
%
%
Contractor Environmental and
Professional Coverage (CEPC) Application
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Well Drilling/Soil Borings
$
%
%
Landfill Construction
$
%
%
Lab Packing
$
%
%
Medical Waste Collection
$
%
%
Tank Removal (Type: )
$
%
%
Tank Installation, Upgrades or Retrofit
(Type: )
$
%
%
Tank Cleaning (Type: )
$
%
%
Environmental Dredging
$
%
%
Asbestos/Lead Abatement
$
%
%
Mold Remediation Services
$
%
%
Demolition/Deconstruction/Dismantling
$
%
%
PCB Retrofit, Removal and Disposal
$
%
%
Other (Specify):
$
%
%
Total All Contracting Services
$
%
%
SECTION III –PROFESSIONAL LIABILITY COVERAGE N/A
1.
Description of Professional Services provided by the Applicant’s Company:
2.
The Applicant’s Projected 12 Month Gross Revenue by Project Type
Category
Percentage
Category
Percentage
Apartments
%
Industrial/Manufacturing
%
Assisted Living and Retirement
%
Marine
%
Single Family Homes and Townhomes
%
Mining, Petroleum or Chemical
%
Commercial Office or Retail
%
Road/Highway
%
Condominiums - High Rise
%
Tunnels/ Bridges/Mass Transit
%
Environmental
%
Schools: K-12 or University
%
Hospital/Medical Facilities or Offices
%
Water or Waste Water Plants
%
Hotels/Motels
%
Other (Describe):
%
3.
The Applicant’s Projected 12 Month Gross Revenue by Client Profile
Client
Percentage
Client
Percentage
Contractors
%
Industrial –Manufacturers/ Logistics
%
Design Professionals/ Consultants
%
Institutional
%
Developers
%
Bankers/ Financiers
%
Government-Federal
%
Real Estate Managers
%
Government-State or Local
%
Other (Specify):
%
3a.
What percentage of current revenue is from repeat clients?
%
4.
What percentage of the Applicant’s current fiscal year gross revenue is Green Building Related?
%
New Construction +
%
Renovation Retrofit =
% Total
4a.
How many of the Applicant’s staff members are LEED Accredited?
5.
Does the Applicant utilize Building Information Modeling on any projects?
Yes
No
6.
Project Delivery Methods
Delivery Method
Last Completed Fiscal Year
Estimated Current Fiscal Year
Construction Only – without any obligations for design or
Construction Management Agency
Payroll:
Construction Values:
Payroll:
Construction Values:
Construction Management Agency – holding no design or
construction subcontracts.
Fees:
Construction Values:
Fees:
Construction Values:
Construction Management At Risk – provides consulting
services during preconstruction and self performs or holds
and manages construction subcontracts during
construction phase
Fees:
Construction Values:
Fees:
Construction Values:
Design/Build with in-house design – assume contractual
obligations for design and construction where design is
substantially performed in-house
Fees:
Construction Values:
Fees:
Construction Values:
Design/Build with subcontracted design – assume
contractual obligations for design and construction where
design is substantially subcontracted to others
Fees:
Construction Values:
Fees:
Construction Values:
Design Services – performed for others with no contractual
obligations for construction or Construction Management
Fees:
Construction Values:
Fees:
Construction Values:
Totals:
Fees:
Construction Values:
Fees:
Construction Values:
Contractor Environmental and
Professional Coverage (CEPC) Application
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(A) + (B) = 100%
Professional Service
Projected Revenue
Next Twelve (12)
months
(A)
Percent retained
In-House
(B)
Percent Work
Subcontracted
Architecture
$
%
%
Construction or Project Management
$
%
%
Building Envelope Consulting
$
%
%
Electrical Engineering
$
%
%
Geotechnical, Foundations or Soil
$
%
%
HVAC/ Mechanical Engineering
$
%
%
Process Engineering
$
%
%
Structural Engineering
$
%
%
Landscape Architecture
$
%
%
Land Surveying
$
%
%
Software/IT/ IS Design or Consulting
$
%
%
Other (Specify):
$
%
%
Environmental Professional Services
Environmental Engineering
$
%
%
Remedial investigation/ feasibility studies
$
%
%
Environmental Audits/ Assessments
$
%
%
Environmental Due Diligence Services
$
%
%
Phase I/ All Appropriate Inquiries Services
$
%
%
Risk Assessments
$
%
%
Air/ Soil/ Water Testing
$
%
%
Lab Testing and Analysis
$
%
%
Bio-Remediation Services
$
%
%
Regulatory Compliance/Permitting
Consulting
$
%
%
Tank Compliance Management
$
%
%
UST Removal Oversight
$
%
%
Tank Installation or Upgrade Consulting
$
%
%
Environmental Dredging
Design/Management
$
%
%
Health and Safety Training/Consulting
$
%
%
Asbestos/ Lead Abatement Oversight
$
%
%
Asbestos/ Lead Testing and Inspection
$
%
%
Indoor Air/ Mold Consulting
$
%
%
Waste Arranging
$
%
%
Waste Brokering
$
%
%
Natural Resource Damage Assessments
$
%
%
Software/ IT/ IS Design or Consulting
$
%
%
Other (Specify):
$
%
%
Total All Professional Services
$
%
%
Total All Contracting and Professional
Services
$
%
%
SECTION IV – NON-OWNED LOCATION COVERAGE N/A
Please provide the following Waste Disposal information:
1.
Has the Applicant ever been in a legal action or suit or given PRP status concerning the disposal
of waste materials?
Yes
No
If yes, please provide details:
Contractor Environmental and
Professional Coverage (CEPC) Application
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SECTION V - THE APPLICANT’S OWNED LOCATION LIABILITY COVERAGE N/A
1.
Location(s) Name and Address
Name
Address
Description and Operation or
Activities Performed
1.
2.
3.
4.
5.
2.
Does the Applicant have any environmental site assessments, questionnaires or air, NPDES or
other discharge permits that have for the Applicant’s location(s) or site(s) listed above?
If yes, please attach.
Yes
No
3.
Are there any existing or historic environmental issues, including reportable discharges or
releases of any hazardous substances or pollutants, or remediation conducted at any of the
Applicant’s locations listed above?
Yes
No
If yes, please describe:
4.
Are there any anticipated changes in use of the location during the policy period?
Yes
No
If yes, please describe:
5.
Hazardous, Toxic or Bulk Materials Stored at The Applicant’s Location
Location Name/
Number
Hazardous, Toxic or Bulk
Material
QUANTITY
(at any one time)
STORAGE
(on pallet, 55 gallon drum, etc.)
6.
Storage Tanks - Please utilize the table and key below provide information about the Applicant’s storage
tanks. UST means underground storage tank. AST means aboveground storage tank.
Are all of the Applicant’s tanks in compliance with the applicable regulations?
Yes
No
If no, please provide details:
WASTE
SOURCE
TYPE OF WASTE MATERIAL
ESTIMATED
QUANTITY
METHOD OF
TRANSPORTATION
DISPOSAL
COMPANY/
WASTE SITE
Owned Location
No(s).:
Project Sites
Construction Debris/Office Trash
Vehicle Maintenance Fluids
Hazardous Material (Specify):
Other (Specify):
per
month
quarter
year
Own vehicles
Third party carrier
(specify):
by:
Owned Location
No(s).:
Project Sites
Construction Debris/Office Trash
Vehicle Fluids
Hazardous Material (Specify):
Other (Specify):
per
month
quarter
year
Own vehicles
Third party carrier
(specify):
by:
Owned Location
No(s).:
Project Sites
Construction Debris/Office Trash
Vehicle Fluids
Hazardou
s Material (Specify):
Other (Specify):
per
month
quarter
year
Own vehicles
Third party carrier
(specify):
by:
Contractor Environmental and
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Location
and Tank ID
No.
UST
AST
Size
(gallons)
Age
Construction
(type of
material and
single wall or
double wall)
Contents
(specify
material)
Leak
Detection
Prevention
Method*
(specify
method)
Containment
(ASTs only)
Piping
**see
key
below
Diked
Yes No
Construction:
Diked
Yes No
Construction:
Diked
Yes No
Construction:
*If tank tightness testing, leak detection or inventory monitoring and control systems, please provide copies of the most
recent test data.
**Piping Key: P= pressure flow, S= suction flow, DBW =double wall, SW = single wall
SECTION VI - RISK MANAGEMENT PRACTICES
1.
Does the Applicant have a person dedicated to risk management practices at the Applicant’s firm
and what percentage of their job responsibilities is considered risk management?
Yes
No
Name and Title:
Percentage of Time:
%
2.
Contract Management
i.
What percentage of the Applicant’s work is performed under written contract?
%
ii.
Are master service agreement utilized?
Yes
No
iii.
Are consensus documents utilized?
Yes
No
iv.
Are Limitation of Liability provisions required in contracts?
Yes
No
v.
Does the Applicant accept consequential damage provisions?
Yes
No
3.
Does the Applicant have a standard contract or purchase order to use with the Applicant’s
subcontractors with indemnification/hold harmless provisions in the Applicant’s favor?
Yes
No
4.
Are subcontractors certificates of insurance retained on file?
Yes
No
5.
Does the Applicant require subcontractors to schedule the Applicant as an Additional Insured?
Yes
No
6.
What limits of insurance does the Applicant require for subcontractors?
General Liability
$
Limit
%
Percentage of Time
Professional Liability
$
Limit
%
Percentage of Time
Contractor Environmental Liability
$
Limit
%
Percentage of Time
with mold coverage?
Yes
No
%
Percentage of Time
7.
Site Safety and Environmental Management
i.
Does the Applicant have a person responsible for site safety management and training?
Yes
No
Name of responsible person and qualifications:
ii.
Does the Applicant have a person trained and responsible for environmental compliance?
Yes
No
Name of responsible person and qualifications:
iii.
Does the Applicant have formal training and protocols for working in areas with
contamination?
Yes
No
8.
Does the Applicant have a formal quality assurance and quality control program?
Yes
No
9.
Does the Applicant have a training program or procedures to managed water intrusion or mold?
Yes
No
If yes, please provide.
10.
Does the Applicant have training program or procedures to control and manage legionella?
Yes
No
If yes, please attach.
11.
Does the Applicant take title or manifest to other’s waste materials?
Yes
No
Contractor Environmental and
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12.
Current Insurance Program
Coverage
Carrier
Limit
Incident/Aggregate
Deductible
Policy
Term/
Expiration
Date
Retroactive
Date
Premium
General Liability
$ /
$
$
Professional Liability
$ /
$
$
Contractor
Environmental Liability
$ /
$
$
Site Environmental
Liability
$ /
$
$
i.
Does the Applicant’s current environmental or professional Liability program provide any
project excess coverage for any projects?
Yes
No
If yes, please describe the situation in detail.
ii.
Has any Underwriter refused, canceled, or non-renewed coverage?
(Not applicable in Missouri)
Yes
No
If yes, please describe the situation in detail.
SECTION VII - LOSS INFORMATION
1.
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 operations?
Yes
No
2.
In the past five (5) years:
a.
Has any claim been made against the Applicant’s company, including any predecessor
companies or any company that the Applicant own control or manager, or any member of
such companies concerning or alleging liability for contamination or as a result of the
Applicant’s professional services or contracting operations ?
Yes
No
b.
Have there been any claims made against the Applicant resulting from the actual or alleged
release of pollutants at, on, under, or from the Applicant’s location for which the Applicant is
seeking coverage?
Yes
No
3.
Is the Applicant aware of any fact or circumstance that could reasonably be expected to result in
any professional services or contracting services or environmental liability claim, suit, government
action or notice of incident against the Applicant’s company or any party to this insurance?
Yes
No
Contractor Environmental and
Professional Coverage (CEPC) Application
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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 and
Professional Coverage (CEPC) Application
Page 9 of 9
© 2020 Philadelphia Consolidated Holding Corp.
07/2020
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Form 1.: CONTRACTOR ENVIRONMENTAL AND PROFESSIONAL COVERAGE (CEPC) (Philadelphia Insurance Companies)

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Completed 11 February 2021

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