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- PRIMARY APPLICATION
ENVIRONMENTAL CONTRACTORS & CONSULTANTS – GL / CEC / PROFESSIONAL PACKAGE
INSTRUCTIONS
• Please answer all questions completely. If any question does not apply, please check “no" or state “N/A”
• If additional space is required, please provide on separate sheet and reference the section and question number
• This form must be signed and dated by an owner, partner, director / officer or principal of the Applicant
SUBMISSION REQUIREMENTS
1.
Applicant’s website address, or a company brochure, describing their experience, skills and representative projects.
2.
Resumes or statement of qualifications for those employees who perform professional services (design, consulting, etc.)
3.
A copy or description of the Insured’s internal Peer Review or other Quality Assurance and Control Procedures.
4.
A copy of the cover page and table of contents for Applicant’s Safety & Health Plan.
5.
Currently valued insurance company loss runs for the current policy period plus three (3) prior years for any GL,
Contractors Pollution, Professional Liability and Excess policies held by the Applicant.
Provide claim and loss details for any open claim or losses over $10,000 incurred.
SECTION I - APPLICANT
1.
First Named Insured:
Date:
Mailing Address:
City:
Zip:
Additional Locations:
1.
(or attach add’l sheet)
2.
3.
Website Address: www.
Risk Management Contact:
Title:
Risk Management’s Email:
Phone:
Company is:
Individual
Partnership
Corporation
Limited Liability Corporation
Joint Venture (describe):
Other (describe):
2.
Date entity was established:
Year environmental operations began:
3.
In which states does the Applicant perform its work?
4.
In the past 5 years, percentage of work performed in New York State: %
5.
In the past 5 years, has the Applicant performed any work in New York City (5 boroughs)?
Yes
No
6.
Does the Applicant plan to perform future work in New York State or New York City?
Yes
No
7.
Any acquisitions, mergers or discontinued operations in the last five (5) years?
Yes
No
If yes, please describe:
8.
List all current and prior entities and affiliated or subsidiary companies to be included as additional Named
Insureds (include a general description and revenues for each) – attach separate sheet as necessary.
9.
Total Employees
Personnel Breakdown
Architects: Environmental Engineers: Mechanical Engineers:
Chemists: Field Personnel: Microbiologists:
Civil / Structural Engineers: Geologists/Hydro Geologists: Principals / Owners:
Clerical: H & S / Risk Managers: Supervisors & Foreman:
Electrical Engineers: Industrial Hygienists: Other:
E-PAC Primary Application
Page 1 of 8
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
Clear Application
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SECTION II - COVERAGES
1.
In-force coverage – OR provide full expiring policy forms & endorsements
No Prior Coverage
General Liability Contractors Pollution Professional Liability
Excess
(See Excess
App)
Carrier
Effective Date
Expiration Date
Limits (Each / Agg)
$ / $
$ / $
$ / $
$
Deductible / SIR
$
$
$
$
CM / OCC – Retro Date
CM
Expiring Premium
$
$
$
$
In-Force coverage – MOLD
No Prior Mold Coverage
Contractors Pollution Liability
Professional Liability
Excess
Covered
Excluded
Covered
Excluded
Covered
Excluded
Occurrence
Claims Made
Mold Retro Date:
Mold Retro Date:
Sub-limited on XS
Yes
No
Mold Deducible:
$
Mold Deducible:
$
XS Mold Limits:
$
2.
Requested Coverages – Effective Date:
General Liability
Contractors
Environmental
Professional Liability
Excess (See
XS App)
Limits (Each / Agg)
$ / $
$ / $
$ / $
$
Deductible / SIR
$
$
$
$
Retroactive Date
3.
Coverage Add-Ons Requested
EBL – Retro Date:
Premises Environmental – S & A
Hired & Non-Owned Auto (Additional Information Required)
Project Specific Increase of Limits*
Non-Owned Location – Retro Date
Stop Gap (WA / WY / ND / OH / WV)
Per Project General Aggregate
Transportation Environmental Liability
Premises Environmental – Full (Additional Information Required)
* If the Applicant requires project specific increased limits, please provide details of the project, and the limits required:
SECTION III – CLIENT TYPES / JOB SITES
1.
REVENUE breakdown by Client Type / Job Site
INDUSTRIAL
RESIDENTIAL / HABITATIONAL
Manufacturing / Chemical Plant
%
Apartment / Dormitories
%
Petrochemical / Refineries
%
Single Family homes
%
Pipelines:
%
Condos / Townhouses
%
Natural Gas
%
Tract Housing
%
Petrochemical
%
Nursing Homes
%
Other:
%
Prisons / Correctional Facilities
%
Wastewater Sewage Plants
%
Potable Water Systems
%
COMMERCIAL / PUBLIC
Other Processing Plants
%
Shopping Centers
%
Power Plants / Transformer Stations
%
Office/Warehouses
%
Other (please describe):
%
Parking Structures
%
Churches
%
INFRASTRUCTURE
Sports / Convention
%
Airports & Runways
%
Schools / Colleges
%
Street/Roads
%
Hospitals
%
Bridges & Tunnels
%
Airport Terminals
%
Harbors / Piers / Ports / Dams
%
Hotels/Motels
%
Offshore Marine
%
Landfills / Disposal Facilities
%
MUNICIPAL / GOVERNMENTAL
Mass Transit / Railroad
%
DOD / DOE / Federal / Homeland Security
%
Nuclear Facilities
%
State/Local
%
E-PAC Primary Application
Page 2 of 8
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
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SECTION IV – OPERATIONS & REVENUES
1.
Projected Gross Revenue
Projected Gross Revenue for the next 12 month period:
$
Foreign:
%
Actual Gross Revenue for the 1
st
prior 12 month period:
$
Foreign:
%
Actual Gross Revenue for the 2
nd
prior 12 month period:
$
Foreign:
%
2.
Sub-contracted Work & Risk Transfer
a.
Does the Applicant use sub-contractors or sub-consultants to perform any portion of its work?
Yes
No
b.
When relevant, does the Applicant require its subs to carry Pollution coverage?
Yes
No
c.
When subs are used, does the Applicant obtain Certificates of Insurance from the subs?
Yes
No
d.
Does the Applicant require subs to add them as Additional Insureds on their GL & Pollution
policies?
Yes
No
e.
What are the minimum Limits of Liability that the Applicant requires from its subs?
General Liability:
$
Contractors Pollution Liability:
$
Professional Liability:
$
3.
Transportation Environmental Coverage
a.
Does the Applicant ever use 3
rd
Party Transportation Companies to transport their waste?
Yes
No
If yes:
i.
Does the Applicant verify that the transporter is properly licensed and permitted?
Yes
No
ii.
Does the Applicant verify that the transporter’s insurance includes pollution and MCS-90?
Yes
No
b.
Is the Applicant seeking coverage for 1
st
Party Transportation Environmental Liability coverage?
Yes
No
If yes, please complete the following:
Total Number of Applicant’s vehicles hauling hazardous materials or potential contaminants, by type:
Type of Vehicle
No. of Units
Type of Vehicle
No. of Units
Private Passenger & Light Trucks:
Extra Heavy Trucks or Truck Tractors:
Medium Truck:
Railcar or Rolling Stock:
Heavy Trucks:
Watercraft or Barge:
c.
Identify the materials that the Applicant transports:
d.
What is the average mileage per trip hauling potentially hazardous or polluting materials?
e.
Is the Applicant required to maintain an FMCSA Hazardous Materials Safety Permit?
Yes
No
If yes, is that permit in good standing?
Yes
No
f.
Has the Applicant incurred a loss related to pollution in transportation within the last four years?
Yes
No
4.
Waste Brokering or Arranging
a.
Does the Applicant select or recommend disposal sites on behalf of or for its clients?
Yes
No
b.
Does the Applicant take title to any waste or cargo at any time?
Yes
No
c.
Does the Applicant verify that the landfill / disposal site is properly classified to accept the waste?
Yes
No
d.
Does the Applicant verify that the landfill / disposal site is properly insured?
Yes
No
5.
Premises Environmental Liability
a.
Do the Applicant’s facilities consist of offices and/or contractor’s yard only, with no Haz Mat or
processing activities?
Yes
No
b.
Which, if any, of the following occur at the Applicant’s owned or operated facilities: (check all the apply)
Temporary Storage of Asbestos or LBP Materials
Landfill or Waste Disposal
Storage or Transfer Facility
Small Quantity Generator –Conditionally Exempt
Large Quantity Generator
Testing Laboratories
Manufacturing, Fabrication or Assembly Activities
Underground Storage Tanks
Air Emissions
Fixed Base Operations (FBO)
Ongoing Operation & Maintenance (O & M) of a facility for others
SECTION V – RISK MANAGEMENT AND BEST PRACTICES
1.
Safety Practices
a.
Does the Applicant have a written Safety & Health Plan for its on-premises and jobsite activities?
Yes
No
b.
Does the Applicant provide an industry-relevant Safety Training Program for its employees?
Yes
No
c.
Does the Applicant implement an Auto Safety and Vehicle Maintenance program, or DOT Safety
Management Plan?
Yes
No
IMPORTANT
Please thoroughly complete the REVENUE BREAKDOWN SCHEDULE at the end of this Application. The sum of all
Contracting & Consulting / Engineering revenues must equal your PROJECTED GROSS REVENUE for the next 12 months.
E-PAC Primary Application
Page 3 of 8
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
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2.
Contracts
a.
Percentage of jobs performed under the following types of client agreement:
Insured’s Written Contract:
%
Letter Agreement:
%
%
Client’s Written Contract:
%
Verbal Agreement:
%
%
b.
How are non-standard client or sub-contractor agreements reviewed?
Agent Review
In-House Attorney
Outside Attorney
Staff (describe):
c.
Does the Applicant utilize a Limitation of Liability of a specified dollar amount in its contracts?
Yes
No
If yes, what is the amount: $
d.
When consulting, do the Applicant’s reports include a disclaimer regarding 3
rd
party reliance?
Yes
No
e.
Does the Applicant utilize the ASTM E1527 Standard protocol when conducting Phase I ESA’s?
Yes
No
f.
Does the Applicant utilize a written contract with sub-contractors / sub-consultants 100% of the
time?
Yes
No
3.
Operations and Procedures
a.
Which of the following Risk Control / Operational Procedures does the Applicant commonly implement on
projects:
Project Specific Safety and Health Plans
Excavation and Underground Utility Risk Prevention Plans
Dust Control and Prevention Plans
Soil – Waste – Hazmat Site Management Plans
Storm Water Pollution Prevention Plans (SWPPP)
Daily Toolbox or Tailgate Talks or Briefings
4.
Quality Control and Quality Assurance
a.
Does the Applicant implement a Quality Control / Assurance Program for its construction
projects?
Yes
No
b.
Does the Applicant have a Quality Control / Assurance Program for its design / consulting
projects?
Yes
No
c.
Has the Applicant implemented a Risk Management Action Plan or Applied Best Practices
system?
Yes
No
d.
Indicate which of the following risk management and best practices are utilized by the Applicant:
Detailed Scope of Services (SOS)
Dedicated Project Management
Internal Peer Review of Reports
Strategic Client /Project Selection
Alternative Dispute Resolution
Termination & Suspension Procedures
Customer Service Department
Client Satisfaction Surveys
Other:
SECTION VI – MOLD, ASBESTOS AND LEAD BASED PAINT
1.
For the immediate past four year period, have there been any known incidents, claims or other
circumstances concerning the existence, growth or presence of mold resulting from any of the
Applicant’s previous work or services?
Yes
No
If yes, please provide details re: Claimant, nature of claim, amount paid or estimated and current status:
2. Does the Applicant have contracting personnel on staff with licensing or certification in mold
abatement?
Yes No
3. Does the Applicant have professionals on staff with formal training in mold testing and assessment? Yes No
4. Is there an established protocol/practice for preventing mold & water intrusion on the Applicant’s jobs? Yes No
5. Does the Applicant have licensed Asbestos and/or Lead-based Paint (LBP) Abatement Contractors on
staff?
Yes No
6. Does the Applicant have licensed Asbestos and/or LBP Abatement Project Designers/Supervisors on
staff?
Yes No
7. Does the Applicant have a Certified Lead-Safe Renovator (RRP) on staff? Yes No
8. Is the Applicant properly licensed for all types of asbestos and LBP work/services that it performs? Yes No
Please provide documentation of the above Qualifications, Protocols, Certifications, etc. as referenced – PRIOR TO BINDING
SECTION VII – CLAIM HISTORY
1. Has the Applicant or any staff member or employee of Applicant ever been subject to disciplinary
action by authorities as a result of their professional or contracting activities?
Yes No
2. With the last four (4) years, have any claims been previously made against the Applicant or reported
under any General Liability, Contractors Pollution Liability or Professional Liability policies?
Yes No
If yes, please describe:
3.
Is the Applicant aware of any fact, circumstance or situation which could reasonably be expected to
result in a claim being made against them or any other person or entity for whom coverage is being
sought? If yes, please describe:
Yes
No
E-PAC Primary Application
Page 4 of 8
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
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REVENUE BREAKDOWN SCHEDULE
PRODUCTS Designed and/or Sold by the Applicant - With and Without Installation (if any)
Estimated Gross Revenue from Products Sold
Product Designed and/or Sold by You with Installation
Describe:
$
Product Design and/or Sold by You without Installation
Describe:
$
REVENUE BREAKDOWN by Operational Classification
ENVIRONMENTAL
CONTRACTING CLASSES
% Sub-contracted ↓
ENVIRONMENTAL
CONTRACTING CLASSES
% Sub-contracted
↓
GROSS
REVENUE
GROSS
REVENUE
Asbestos and Lead Abatement (incl. related demo)
- Residential or Habitational
PCB Removal
Asbestos and Lead Abatement (incl. related demo)
- Commercial or Industrial
Phyto or Bio Remediation
Barrier or Liner Construction (not landfill)
Pipeline Construction and Repair
Disposal Fees for Waste or HAZ Materials
(Not packing, loading or hauling fees)
Recycling (Chemicals or Hazardous Materials)
Dredging (Pollution Related only)
Sample Collection – Asbestos & Lead or Other
Drilling (Env. monitoring or treatment wells)
Sample Collection – Soil or Groundwater
Emergency Response Cleanup/Spill Response
Soil Remediation – Excavation/Dig & Haul
Groundwater Remediation
Soil Remediation – In Situ
Hazardous Material Cleanup (NOT Soil or GW)
Solar Installations (Photovoltaic and Hot Water):
- Residential or Habitational
Hazardous Waste Treatment (at job site)
Solar Installations (Photovoltaic and Hot Water):
-Residential or Habitational New Tract Home
Construction/ Development
Indoor Air/Radon Mitigation (non-Mold)
Solar Installations (Photovoltaic and Hot Water):
- Commercial or Industrial
Industrial Cleaning (not tank or pipe)
Superfund Remediation Contracting
Lab Packing (Facility Clean-out; Packaging/Loading)
Tank and Pipe Cleaning (confined space)
Landfill Capping and Surface Maintenance
Tank and Pipe Cleaning (remote/robotic)
Landfill Construction or Expansion
Tank Installation & Removal – Aboveground Only
Landfill Liner Installation
Tank Installation – Underground
Medical Waste Pickup and Transportation
Tank Removal – Underground
Medical Waste Processing or Remediation
Tank Maintenance and Repair
Mobile Incineration / Thermal Treatment / Solvent
Distillation
Transportation/Haul Away of Wastes & Haz Mats
(NOT Including Packing or Loading)
[Does NOT include Well Field Saltwater Hauling]
Mold Remediation (incl. related demo)
- Residential or Habitational
Waste Stream Treatment System Construction
(not sewage or potable water treatment systems)
Mold Remediation (incl. related demo)
- Commercial or Industrial
Wetland and Habitat Restoration Contracting
Other:
Wind Turbine Installation and Maintenance
Other:
TOTAL ENVIRONMENTAL CONTRACTING REVENUE:
$
Please read through all operational classifications within each category and identify those services which you provide. Then allocate
100% of your projected Gross Revenue for the next 12 months (from Page 3) to the specific classifications of Contracting and
Consulting/Engineering Services you perform. For each, indicate the Gross Revenue generated from that Classification, and the %
performed by sub-contractors or sub-consultants.
E-PAC Primary Application
Page 5 of 8
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
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REVENUE BREAKDOWN SCHEDULE (Section IV Continued)
NON-ENVIRONMENTAL
CONTRACTING CLASSES
% Sub-contracted ↓
NON- ENVIRONMENTAL
CONTRACTING CLASSES
% Sub-contracted ↓
GROSS
REVENUE
GROSS
REVENUE
Bridge Construction
Masonry – Stone / Brick
Carpet Cleaning (Not as Fire/Water Restoration)
Oil and Gas Leasing
Concrete – Flatwork
Operation and Maintenance (facilities of others)
Demolition (interior, not part of Abatement)
Painting and Coatings Application (NOT Bridges)
Demolition-Structural (1 to 3 stories)
Painting and Coatings – BRIDGES
Demolition-Structural (Over 3 stories)
Paving – Public Streets and Roadways
Dredging (deepening or widening of waterways)
Pesticide and Herbicide Application
(AERIAL)
Drilling (oil/gas)
Pesticide, Herbicide and Fertilizer Application
(NOT Aerial)
Drilling (water wells)
Pile Driving
Drywall
Plastering or Stucco
Electrical
Plumbing – Not Fire Suppression / Sprinklers
Excavation or Grading
Potable Water Treatment System Construction
Finish Carpentry
Railroad Construction and Maintenance
Fire Suppression/Sprinklers Installation
Roofing
Flooring
Sandblasting
Foundation Construction
Scaffold Erection
Framing & Carpentry (general)
Sewage Treatment Plant Construction & Maint.
General Contractor
Sewer and Septic Cleaning & Maintenance
Glazier / Glass and Window
Steel Erection
Home Building / Residential Developers
Temporary Employment Agencies / Labor Force
HVAC and Mechanical Refrigeration
Transportation / Hauling (Non-Environmental)
Insulation (no abatement)
Transportation / Hauling – Well Field Saltwater
Landscaping
Unexploded Ordinance / UXO Removal
Logging
Waterproofing
Marine Construction and Marine Activities
OTHER:
TOTAL NON-ENVIRONMENTAL CONTRACTING REVENUE:
$
ENERGY - Oil & Gas
CONTRACTING CLASSES
% Sub-contracted ↓
ENERGY - Oil & Gas
CONSULTING AND
ENGINEERING CLASSES
% Sub-contracted ↓
GROSS
REVENUE
GROSS
REVENUE
Roustabout
Oilfield Consulting – Observe & Report Only
Rat Hole Drilling
Oilfield Consulting – Direct Supervision
Pad Site and Road Construction or Maintenance
Geophysical / Reservoir Engineering
Pipeline / Gathering Line Construction / Maintenance
Pipeline / Gathering Line Layout and Design
Downhole, Over the-Hole or Production Activities
Oil and Gas Well Engineering
OTHER:
OTHER:
TOTAL NON-ENVIRONMENTAL CONTRACTING REVENUE:
$
E-PAC Primary Application
Page 6 of 8
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
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REVENUE BREAKDOWN SCHEDULE (Section IV Continued)
ENVIRONMENTAL CONSULTING
AND ENGINEERING CLASSES
% Sub-contracted ↓
ENVIRONMENTAL CONSULTING
AND ENGINEERING CLASSES
% Sub-contracted ↓
GROSS
REVENUE
GROSS
REVENUE
Air Quality Testing and Monitoring (non-Mold) Lab Testing / Analysis (environmental)
Asbestos and Lead-Based Paint Assessment,
Remedial Design and Monitoring
Mold Inspection and Assessment
Construction or Project Management – Agency (on
environmental projects)
Phase I or Transaction Screen
Construction or Project Management – At Risk (on
environmental projects)
Phase II – Subsurface Investigation
Decommissioning Design for Radioactive & Nuclear
Facilities
Phase III – Remedial Design Plans and Specs
Energy Efficiency Consulting Pipeline Integrity Testing
Environmental Compliance Training Radon Consulting
Environmental Impact Studies Regulatory Consulting / Permitting
Expert Witness / Litigation Support (environmental) Remediation Oversight / Management
Feasibility Studies or Reports without Design Solar / Photovoltaic System Layout and Design
Geology & Hydrogeology (100% Environmental) Surveying in Support of Environmental Reports
Geophysical Assessments (100% Environmental)
Non-Mining / Non-Oil & Gas
Tanks – UST/AST System Design
Geotechnical (100% Environmental) -
Related to Remediation System Design or Constr.
Tanks – UST/AST Testing
Hazardous Materials Consulting Waste Brokering / Disposal Site Selection
Health and Safety Training Wetlands and Wildlife Consulting or Design
Industrial Hygiene Consulting OTHER:
TOTAL ENVIRONMENTAL CONSULTING REVENUE:
$
NON-ENVIRONMENTAL
CONSULTING AND
ENGINEERING CLASSES
% Sub-contracted ↓
NON-ENVIRONMENTAL
CONSULTING AND
ENGINEERING CLASSES
% Sub-contracted ↓
GROSS
REVENUE
GROSS
REVENUE
Architectural Design Land Surveying (non-environmental)
Building Condition Inspectors / R.E. Audits Landscape Architecture
Civil Engineering Marine Engineering
Construction or Project Management – Agency
(non-environmental projects)
Mechanical Engineering
Construction or Project Management – At Risk
(non-environmental projects)
Mining Engineering
Electrical Engineering (except Photovoltaic) Pipeline Design
Geology and Hydrogeology (Non Environmental)
Process Engineering - Potable & Sewer / Waste
Water Facilities
Geophysical Assessments (Non Environmental)
Mining and/or Oil & Gas
Process Engineering – Petroleum, Chemical &
Food Industries
Geotechnical Engineering (building construction,
foundation, structural or slope stability related)
Software Design / Programming
HVAC Engineering Structural Engineering
Lab Analysis / Construction Materials Testing
(non-environmental)
OTHER:
TOTAL NON-ENVIRONMENTAL CONSULTING REVENUE:
$
E-PAC Primary Application
Page 7 of 8
© 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.
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)
E-PAC Primary Application
Page 8 of 8
© 2020 Philadelphia Consolidated Holding Corp.
04/2020
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- PRIMARY APPLICATION (Philadelphia Insurance Companies)

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Completed 7 November 2020

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