PEC Supplemental Claim Form (06/10) Page 1 of 3
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Name of Insurance Company to which Application is made (herein called the “Insurer”)
PREMISE ENVIRONMENTAL COVERAGE
SM
APPLICATION
SUPPLEMENTAL CLAIM INFORMATION
Submit one form for each claim or incident. If space is insufficient to answer any question completely,
please use the Additional Information page attached to this application.
1. Full name of the Applicant Firm:
2. Full name of the Firm which reported the claim (if different from above):
3. Full name of the Claimant:
4. Indicate whether: Claim / Suit Incident / Potential Claim Remediation Expense
5. Date / Period of incident that led to claim:
6. Date the claim was reported to the insurance carrier:
7. Indicate whether: Claim Covered Denied Self Insured
8. Other parties against which this claim is made:
9. This claim is: Open Closed
10. If CLOSED, indicate the date closed:
11. Please complete the following:
If claim is still open:
a. Remediation expenses incurred/Estimate: $
b. Claimant’s settlement demand: $
c. Defendant’s offer for settlement: $
d. Insurance company’s loss reserve: $
e. Deductible: $
f. Total loss and expenses paid to date: $
If claim is closed:
a. Remediation expenses incurred: $
b. Loss paid in excess of deductible: $
c. Expenses paid in excess of deductible: $
d. Deductible: $
e. Settlement reached via:
Court Judgment Formal mediation/Arbitration proceeding Out of court settlement
f. Type of remediation:
Voluntary program Formal mediation/Arbitration proceeding Regulatory settlement
Note: If information is not available, please provide a copy of the suit papers.
