Fillable KINSALE Premises Environmental Liability Application

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KINSALE Premises Environmental Liability Application

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Page 1 of 6
PREMISES ENVIRONMENTAL LIABILTY APPLICATION
COMPLETE IN ADDITION TO ACORD APPLICATIONS. ATTACH ADDITIONAL SHEETS AS NECESSARY.
ANSWER ALL QUESTIONS. APPLICATION MUST BE SIGNED BY THE APPLICANT. INCOMPLETE APPLICATIONS WILL NOT BE
CONSIDERED FOR COVERAGE. If not applicable, indicate N/A.
1. Applicant Information:
Name:
Mailing Address:
City: State: Zip:
Website: www.
Applicant is a: Individual Partnership Corporation Joint Venture Other
2. Requested Coverage: Third Party Pollution Liability Onsite Cleanup
3. Limits Requested: $500,000/$500,000 $1,000,000/$1,000,000 $1,000,000/$2,000,000
4. Deductible Requested: $5,000 $10,000 $25,000 $50,000
5. Expected annual revenues:
6. Annual revenues for the last 12 months:
7. Please provide facility, address, state and zip code for all locations needing coverage.
Facility Address Description of Operations Historical Operations
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 6
8. Are all of these locations currently in compliance with federal, state, and local Yes No
environmental regulations? If so, please describe.
9. Are any of these locations currently undergoing corrective action or active remediation? Yes No
If so, please describe.
10. Have any of these locations ever undergone corrective action? Yes No
If “yes, please provide details:
11. Have any of these locations received an environmental violation? Yes No
If so, please provide details.
12. Are there structures on these properties? Yes No
If so, please describe.
13. Have these structures been tested for asbestos, radon, and lead paint? Yes No
(Only complete if properties requesting coverage generate, dispose of, stores, or handles hazardous waste or materials.)
1. Please describe types of hazardous waste or materials.
2. Please describe disposal method.
3. Please describe on site storage practices and areas.
HAZARDOUS WASTE
Page 3 of 6
Installation Date
Capacity
(in gallons)
Contents
Tank Construction
Secondary
Containment
Chemical
Name
Total
Quantities
per year
Total
Quantities
on hand
at a time
Storage Methods
Drum AST UST Other
1. Please describe adjacent properties:
North
South
East
West
2. Are there nearby bodies of water? Yes No
If so, please include description and distance.
3. Are there nearby protected environments (i.e., parks or wetlands) or schools? Yes No
If so, please describe.
ABOVE GROUND STORAGE TANK INFORMATION
CHEMICAL INFORMATION
SURROUNDING PROPERTIES
Page 4 of 6
4. Is public water and sewer available and in use at locations requesting coverage? Yes No
(Please complete only if location(s) requesting coverage include landfill.)
Total Acreage Acreage of Active Area Acreage of Closed Area Permitted but not in
use acreage
1. Type of waste accepted:
2. Is the landfill lined? Yes No
If yes, please advise type of liner, material, and thickness:
3. Is there a leachate collection system in place? Yes No
a. How much is produced annually?
4. Are daily operating procedures in place? Yes No
5. Are emergency procedures in place? Yes No
6. How many active groundwater monitoring wells are in place?
(Attach copies of most recent groundwater analytical data for all wells.)
(Complete if your facility treats, processes, or stores any type of waste.)
Type of wastes accepted
Maximum amount processed per day
Maximum amounts stored at any one time
Describe processes used at the facility
When were Title III Reports updated
1. Please describe any pollution claims that have occurred in the last five years.
LANDFILL
WASTE
GENERAL HISTORY
Page 5 of 6
2. Have you received any violations regarding any federal, state, or local agency relating Yes No
to the release of a substance from your location(s) into sewers, rivers, air, or land?
If so, please provide details.
3. 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.
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.
Page 6 of 6
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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KINSALE Premises Environmental Liability Application

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Completed 2 July 2020

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