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GOLF COUNTRY CLUBS PREMISES ENVIRONMENTAL COVERAGE (PEC) APPLICATION (Philadelphia Insurance Companies)

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GOLF – COUNTRY CLUBS
PREMISES ENVIRONMENTAL COVERAGE (PEC) APPLICATION
INSTRUCTIONS:
1. If additional space is required to complete an answer, please provide supporting information on
your firm’s letterhead and reference the application question number of the sheet.
2. This form must be signed and dated by an owner, partner, director/officer or principal of the
Applicant.
SUBMISSION REQUIREMENTS
•
Environmental permits or licenses such as NPDES, sewer discharge or treatment permit, hazardous
waste or materials storage permit or storage tank permit
•
Inventory list/quantity used of herbicides, pesticides, fertilizers, chemicals or hazardous materials
•
Pesticide applicator licenses
•
Most recent results of petroleum tank tightness tests, leak detection/inventory monitoring and control
systems
•
Any environmental audits or site assessments
•
Copy of expiring environmental policy
Section I – GENERAL INFORMATION
Club Name: Website:
Business Address:
Telephone Number: Fax Number:
Number of Members
: Number of Holes:
Name / Contact Information of Enviro
nmental Compliance Office Manager:
Address of the location(s) for which you are seeking coverage:
Other Insureds to be listed on the policy and relationship to th
e Named Insured:
Other Insureds Relationship to Insured/Operations
Do you have a PGA Professional on staff? Yes No
Golf - Country Clubs
Premises Environmental Coverage Application
Page 1 of 6
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
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Coverage Request:
Limits and Deductible: (Please put a check next to each optio
n you would like to see.)
DEDUCTIBLE
EACH INCIDENT LIMIT TOTAL POLICY LIMIT POLICY TERM
$5,000 $500,000 $500,000 1 Year
$10,000 $1,000,000 $1,000,000 2 Year
$25,000 $2,000,000 $2,000,000
Other:
$ Other:$ Other:$ Other:
Remediation Expense from Contamination Off-site
Third Party Claims for Bodily Injury and Property Damage (On-site and Off-Site)
Storage Tank Coverage
Waste Disposal Liability
Mold Coverage* - Please Complete Separate Indoor Air Quality and Mold Supplemental Application
Section II – PREMISES OPERATIONS
1. Club Services:
Beauty Shop Stables Pool / Hot Tub Child Care
Hunting / Skeet Ranges / Trap Ranges Hotel / Guest Quarters Marina / Watercraft
2.
Golf Carts fueled by: Propane Gas
Electric
3.
Are cart / mobile equipment batteries stored in dedicated area designed for storage of batteries?
Yes No
4. Is there any surface water on your property? Yes No
5. If yes, what kind (lined pond, intermittent stream, riv
er, etc.)?
6. Are there any potable water wells on the site? Yes No
If yes, is water tested annually? Yes No
Do the results meet federal, state, and local standards? Yes No
7. Is there any third party drinking water wells located within a ½ mile of your location? Yes No
8. Do you have any environmental permits or licenses such as NPDES, sewer discharge or treatment
permit, hazardous waste or materials storage permits, storage tank permit? Yes No
9. Sewage is treated by: septic system on-site waste water treatment plant municipal sewer system
10. For on-site septic or waste water treatment plant only:
a. The system discharge to:
Septic tank Leach field Spray field Aeration pond
Stream Pond Municipal sewer system Other:
b. Is there any piping connecting to areas storing hazardous substances? Yes No
c. Do you process waste water for parties other than the golf club? Yes No
If yes, who and what is the annual volume?
Retroactive Date:
Please check the box for each coverage you would like:
Remediation Expense from Contamination On-site
3 Year
Golf - Country Clubs
Premises Environmental Coverage Application
Page 2 of 6
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
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11. Chemical Usage
a. Do you have certified and/or licensed pesticide / herbicide applicators on staff? Yes No
b. Does the club apply pesticides, herbicides, or fertilizers to its golf course grounds or is that
service provided by a contractor?
If contracted out, does the club obtain certificates of insurance confirming pollution liability
coverage from all contractors? Yes No
c. Chemical Storage:
i. Do you have complete and reconcilable inventory records kept for all chemicals? Yes No
ii. Do you have a dedicated storage room or building for hazardous materials? Yes No
iii. Does this area have floor drains? Yes No
iv. Does this area have secondary containment? Yes No
v. Do you display Material Safety Data Sheets for all hazardous substances in the storage
area? Yes No
vi. Do you have standard operating procedures in the event of a spill? Yes No
vii. Do you have personnel trained in spill response and spill response equipment in the
event of a spill? Yes No
12. Historic Information:
a. Have any of the following operations ever been conducted within the property grounds?
Automobile servicing Landfill Petroleum storage or distribution
Dry cleaning Recycling Waste treatment or storage
b. Are there any abandoned tanks or equipment at the site? Yes No
If yes, have they been closed in accordance with the regulation? Yes No
c. Do you have any environmental site assessments or questionnaires that have been performed
for the site(s) where you would like coverage? Yes No
If yes, please attach.
13. Are there any anticipated changes in use or construction at the location during the policy period? Yes No
If yes, please describe:
Section III – STORAGE TANKS
Please utilize the table below to provide information about your storage tanks and attach pictures of the tanks and copies
of any results of tank tightness testing, leak detection or inventory monitoring and control systems.
1. Are all of your tanks in compliance with the applicable regulations? Yes No
If no, please provide details:
Location
and
Tank ID
Number
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:
Diked: Yes No
Construction:
Diked: Yes No
Construction:
Diked: Yes No
Construction:
Diked: Yes No
Construction:
(UST means underground storage tank. AST means above-ground storage tank.)
**Piping Key: P= pressure flow, S= suction flow, DBW =double wall, SW=single wall, N/A –none
Golf - Country Clubs
Premises Environmental Coverage Application
Page 3 of 6
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
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Section IV – WASTE MANAGEMENT
TYPE OF WASTE MATERIAL
ESTIMATED
QUANTITY
METHOD OF
TRANSPORATION
DISPOSAL COMPANY / WASTE
SITE (Landfill/Rec
ycling Site)
Household Trash
Vehicle Maintenance Fluids
Hazardous Materials/Waste
Other (Specify):
_____per
Month
Quarter
Year
Own vehicles
Third Party Carrier
(Specify):
By:
Household Trash
Vehicle Maintenance Fluids
Hazardous Materials/Waste
Other (Specify):
_____per
Month
Quarter
Year
Own vehicles
Third Party Carrier
(Specify):
By:
Household Trash
Vehicle Maintenance Fluids
Hazardous Materials/Waste
Other (Specify):
_____per
Month
Quarter
Year
Own vehicles
Third Party Carrier
(Specify):
By:
Section V – COVERAGE HISTORY (All Applicants must complete this section)
1. Have you had or do you currently have any environmental insurance in place? Yes No
If yes, provide information below and include a copy of the policy:
Carrier Limit Deductible Policy Term Premium
$ $ $
$ $ $
$ $ $
$ $ $
2. With respect to the above coverage, has any Underwriter refused, canceled, or non-renewed
coverage? (Not applicable in Missouri) If yes, provide details: Yes No
3. In the past five (5) years:
a. Have you been required to do any remediation at the location for which you are seeking
coverage? If yes, please describe: Yes No
b. Have there been any reportable discharges or releases of any hazardous substances or
pollutants at or from any locations for which you are seeking coverage? If yes, please describe: Yes No
c. Have there been any claims made against you resulting from the actual or alleged release of
pollutants at, on, under, or from the site for which you are seeking coverage? Yes No
If yes, please provide details:
4. Are you aware of any fact or circumstance that could reasonably be expected to result in a claim arising
from a release to the environment from the site for which you are seeking coverage? Yes No
Golf - Country Clubs
Premises Environmental Coverage Application
Page 4 of 6
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
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No application will be accepted unless signed by the Applicant
The applicant warrants that all answers to the questions on this application are true and correct. 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 any facts thereto, commits a fraudulent insurance act, which is a crime.
Application Addendum
Philadelphia Insurance Companies or its authorized representatives is hereby authorized to conduct such inquires as necessary to verify all
information contained in this application. Authorization is also given to obtain a personal credit report on the principal of the company.
Golf - Country Clubs
Premises Environmental Coverage Application
Page 5 of 6
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
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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
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
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, 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.
NAM
E (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE DIRECTOR)
_______
______________________________________________________
SIGNATURE DATE
SEC
TION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
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04/2020
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