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PREMISES ENVIRONMENTAL COVERAGE (PEC) APPLICATION-OK (Philadelphia Insurance Companies)

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PREMISES ENVIRONMENTAL COVERAGE (PEC) APPLICATION-OK
SECTION I – GENERAL INFORMATION
Named Insured:
Address:
City: State: Zip:
Telephone Number: Fax Number:
SIC Code: Annual Revenues: $
Website: www.
Risk Management Contact: Risk Management’s Phone:
Risk Management Email:
Other insureds to be listed on the policy and relationship to the Named Insured:
(attach an additional sheet if needed)
Other Insureds Relationship to Insured
Does the Applicant currently have any environmental insurance in place? Yes No
If yes, provide information below and include a copy of the policy and current loss runs.
Carrier Limit
Self-Insured
Retention
Effective and
Expiration
Date Premium
Retroactive
Date
(if applicable)
$ $ $
$ $ $
$ $ $
Requested Coverage
Policy Term Limit
Self-Insured
Retention Effective Date
Retroactive
Date
(if applicable)
$
$
$
$
$
$
With respect to prior coverage, has any Underwriter refused, cancelled, or non-renewed coverage?
(Not applicable in Missouri)
Yes No
If yes, provide details:
THIS IS A CLAIMS MADE AND REPORTED POLICY WITH DEFENSE COSTS INCLUDED IN THE LIMITS OF INSURANCE. VARIOUS PROVISIONS
IN THIS POLICY RESTRICT COVERAGE. READ THE ENTIRE POLICY CAREFULLY TO DETERMINE RIGHTS, DUTIES, AND WHAT IS OR IS NOT
COVERED.
Premises Environmental Coverage (PEC) - OK
Page 1 of 8
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04/2020
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SECTION II – APPLICANT’S INSURED LOCATION INFORMATION
Address of the location(s) for which the Applicant is seeking coverage (attach an additional sheet if necessary)
Address (including City and State)
Square Footage,
Acreage,
# of Units
Year
Built
Current Use
(i.e. Industrial,
Habitational, etc.)
Owned,
Managed
or Leased
1.
Is there any surface water on the Applicant’s location?
Yes
No
If yes, what kind (lined pond, intermittent steam, river, etc.)?
2.
Are there any potable water wells on the Applicant’s location?
Yes
No
If yes, is the water tested annually?
Yes
No
Do the results meet federal, state and local standards? (Please provide most recent results)
Yes
No
3.
Are there third party drinking water wells located within a ½ mile of the Applicant’s location?
Yes
No
4.
Is there a septic system at the Applicant’s location?
Yes
No
If yes, is it connected to areas storing hazardous substances?
Yes
No
5.
Please list the neighbors in the vicinity of the Applicant’s locations and their property use
(i.e. residential, dry cleaner, etc.). (attach an additional sheet if necessary)
Name
Location
Current Use
(i.e. Residential,
Dry Cleaner, etc.)
North
South
East
West
SECTION III – SITE OPERATION AND HISTORY
1.
Does the Applicant have any environmental site assessments or questionnaires that have been
performed for the location(s) where they would like coverage?
Yes
No
If yes, please attach.
2.
Please describe the operations that take place at the location(s) for which the Applicant is seeking
coverage:
3.
Are there any anticipated changes in use of the location(s) during the policy period, including any
planned additions or demolition)?
Yes
No
If yes, please describe:
4.
Are there any plans for interior capital improvements during this policy period?
Yes
No
If yes, please describe.
Premises Environmental Coverage (PEC) - OK
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5.
What are the previous uses of the location?
6.
Has waste ever been disposed of at this location?
Yes
No
If yes, please describe.
7.
Is there a dry cleaner at the location?
Yes
No
8.
Are there any abandoned tanks or equipment at the location?
Yes
No
If yes, have they been closed in accordance with regulation? (Please provide documentation)
Yes
No
9.
Please provide the following raw materials used and / or stored on the Applicant’s location:
(attach an additional sheet if necessary)
Material Name
Quantity On-Site
(at any one time)
Storage
(on pallet, 55 gallon drum, etc.)
SECTION IV - WASTE
1.
Has the Applicant ever been in a legal action or suit or given PRP status concerning the disposal of
waste materials? If yes, attach details.
Yes
No
2.
Please provide the following information: (attach an additional sheet if necessary)
Type of Waste
Quantity
(at any one time)
Method of Storage
On-Site
Disposal Method (Including
Name of 3
rd
Party Hauler)
SECTION V - TRANSPORTATION
Transport Environmental Coverage
1.
What materials are being transported to and from the Applicant’s location?
2.
Please describe the conveyance and containment: (i.e. 55 gallon drum in pickup truck)
3.
How often is the Applicant’s material picked up and who is the carrier?
Premises Environmental Coverage (PEC) - OK
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4.
Please provide the following information on the vehicles the Applicant operates by vehicle type.
Vehicle Type
# of Units
Cargo or Material Hauled
(indicate if hazardous)
Radius of Operation
Private Passenger
Light Truck
Medium Truck
Heavy/Extra Heavy Truck
Trailers
Railcar
Watercraft
Aircraft
SECTION VI - STORAGE TANK
Please utilize the table and key below to provide information about your storage tanks.
UST means underground storage tank. AST means above-ground storage tank.
1.
Are all of the Applicant’s tanks in compliance with the applicable regulations?
Yes
No
If no, please provide details:
2.
Please complete the information below for the tanks you would like covered.
Tank
No.
UST
AST
Size
(Gallons)
Age
Construction
(Material,
Single or
Double Wall)
Contents
(specify
material)
Leak
Detection
Prevention
Method
(specify for
tank and
piping)*
Containment
Is the AST
diked?
Construction
of dike?
Piping**
see key
below
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
*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 VII – MOLD AND LEGIONELLA
1.
Have any of the Applicant’s locations had mold growth or legionella incidents where costs are expected
to exceed $25,000?
Yes No
If yes, please describe:
Premises Environmental Coverage (PEC) - OK
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2.
Does the Applicant have a written mold management / water intrusion plan for their insured locations?
Yes
No
Please provide a copy.
3.
Are there any visible signs of mold growth at any of the Applicant’s locations?
Yes
No
If yes, please describe.
4.
Have any construction / maintenance defects been encountered (i.e. HVAC system problems, roof
leaks, window or siding leaks) which resulted in water intrusion, indoor air quality or mold-related
issues?
Yes
No
If yes, please describe.
5.
Does any of the Applicant’s insured locations have buildings with Exterior Insulation Finish System
(EIFS)?
Yes
No
If yes, please describe the age, type of system, inspection schedule, and any water intrusion issues.
6.
Have any indoor air quality, legionella or mold studies or inspections been performed at the Applicant’s
location(s)? If yes, please provide a copy.
Yes
No
7.
Have there been any complaints for odor, indoor air quality, legionella or mold at any of the Applicant’s
locations?
Yes
No
If yes, please describe.
8.
Does the Applicant have a dedicated on-site property manager for their locations?
Yes
No
If yes:
a.
Is the property manager an employee?
Yes
No
b.
Unrelated property manager?
Yes
No
If yes, please provide name/ address of firm and information regarding environmental insurance
coverage.
SECTION VIII – LOSS HISTORY
Must be completed by all Applicants
1.
In the past five (5) years:
a.
Has the Applicant been required to do any remediation at the location for which you are seeking
coverage?
Yes
No
If yes, please describe.
b.
Have there been any reportable discharges or releases of any hazardous substances or pollutants
at or from any locations for which the Applicant is seeking coverage?
Yes
No
If yes, please describe.
Premises Environmental Coverage (PEC) - OK
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c.
Have there been any claims made against the Applicant 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.
2.
Is the Applicant aware of any fact or circumstance that could reasonably be expected to result in a claim
arising from contamination (including mold or legionella) at or from a location for which the Applicant is
seeing coverage?
Yes
No
If yes, please provide details.
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.
Premises Environmental Coverage (PEC) - OK
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WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterization revie
w?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
monitoring,
heat trace, full insulation on piping or roof):
6.
General Comments:
Premises Environmental Coverage (PEC) - OK
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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, 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 OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECTION 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)
Premises Environmental Coverage (PEC) - OK
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04/2020
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