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STORAGE TANK APPLICATION This application is for single (Access E&S Insurance Services)

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The STORAGE TANK APPLICATION This application is for single (Access E&S Insurance Services) form is 8 pages long and contains:

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  • 43 check-boxes
  • 148 other fields

Country of origin: US
File type: PDF

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Page 1 of 8
STORAGE TANK APPLICATION
NOTICE
This application is for single location. Section III and IV should be filled out for each
additional location. Please answer all questions. Use additional sheets of paper if necessary.
This policy provides that aggregate defense expense limit separate from the liability that
applies to Loss, Corrective Action and Cleanup costs shall be reduced by amounts incurred
for legal defense. Further note that amounts incurred for legal defense shall be applied
against the deductible amount.
Please forward:
Environmental Reports (Audits, Phase I, Phase II Reports, and Remedial Action Work
Plans) on locations under remediation or investigation.
Most recent leak detection results for all underground storage tanks.
SPCC Plan if available.
Audited financials for the past two years.
Schedule of Environmental policies and associated loss experience for the past two (2)
years.
Declaration Page and Endorsements from expiring policy
The insurer with which the licensee places the insurance is a surplus lines insurer, is not
licensed by the State, and is subject to limited regulation. In the event of insolvency of the
insurer, this insurance in not covered by the Guaranty Fund or Guaranty Association
This application can be filled out electronically or by hand. If not applicable, answer N/A.
I. ADMINISTRATIVE INFORMATION
1. Named Insured:
2. Named Insured’s Address:
3. Contact Name and Title:
4. Phone Number:
5. Company Website: www.
Page 2 of 8
6. Applicant is: Corporation Partnership
Sole Proprietor Joint Venture
Other (Please Specify)
7. Please List Additional
Insureds (if applicable):
8. Total number of Locations
to be insured:
II. COVERAGE REQUESTED
Incident
Limit
Aggregate
Limit
Deductible Proposed Effective &
Expiration Dates
1. Coverage:
2. Requested Coverage as Expiring? YES NO
3. Expiring Carrier:
4. Expiring Premium:
5. Insuring Agreements Requested: Coverage A: Third Party Bodily Injury and
Property Damage
Coverage B: Corrective Action Due to
Underground Storage Tank Releases
Coverage C: Cleanup of Pollutants Due to
Aboveground Storage Tank Release
On Site Bodily Injury and Property
Damage (by endorsement)
(Please remember to fill out Sections III and IV for each location)
Page 3 of 8
III. UNDERGROUND STORAGE TANK SCHEDULE
1. Location Name & Address:
2. Location Number: of (Example: x of y)
3. Use of Facility:
4. Leased or Owned: Leased Owned
5. Date Acquired:
(See chart below for instructions and abbreviations)
Tank
#
Year
Installed
Tank
Capacity
(Gallons)
Tank
Construction
(specify all
that apply)
Contents Overfill
Protection
(Y/N)
Regulatory
Compliance
(Y/N)
Leak
Detection
Tank Construction Contents Regulatory Compliance Leak Detection
DW = Double Walled/Secondary
Containment
F = Fiberglass
S = Coated or Bare Steel
F/S = FRP Clad Steel
STI = (STI- P3) Steel Tank
Institute T.P.
FRP = Single Walled Fiber
Reinforced Plastic
CP/S = Cathodically Protected
Steel
R = Relined
O = Other (Please Specify)
RG = Reg. Gasoline
UG = Unleaded Gas
D = Diesel
K = Kerosene
NO = New Oil
WO = Waste Oil
HO = Heating Oil
O = Other (Please
Specify)
DENOTES A TANK
MEETING US EPA
TECHNICAL AND LEAK
DETECTION STANDARDS
ATM = Auto Tank
Monitoring
GW = Groundwater Wells
SIA = Statistical Inventory
Analysis
IM = Interstitial Monitoring
TT = Tightness Tests**
**Show last test date and
indicate result – P/F
(Pass/Fail). Proof of
tightness test results must
be submitted to underwriter
Page 4 of 8
6. a. Has any storage tank ever been removed from
this location or closed in place?
b. Is this site currently under investigation or
remediation?
YES NO (If yes, a “Closed in
Place” or “No Further Action” letter must
be provided.
YES NO ( If yes, please provide
copies of site assessments and any
analytical soil/groundwater data available)
7. Is there a history of leaks or releases at this
facility related to underground storage tanks
not stated above?
YES NO (If yes, please describe
below)
8. Is any technology in place to prevent or detect a leak?
YES NO (If yes, please
identify)
9. Is the owner of the property the same as the
owner of the storage tanks?
YES NO (If no, please explain
the relationship of the tank owner to the
property owner.)
Page 5 of 8
IV. ABOVE GROUND STORAGE TANK SCHEDULE
1. Location Name & Address:
2. Location Number: of (Example: x of y)
3. Use of Facility:
4. Leased or Owned: Leased Owned
5. Date Acquired:
(See chart below for instructions and abbreviations)
Tank # Year
Installed
Tank
Capacity
(Gallons)
Tank
Construction
(specify all
that apply)
Contents Overfill
Protection
(Y/N)
Leak
Detection
AST Diking
& Base
Const.
Tank Construction Contents AST Diking and Base
Construction
Leak Detection
DW = Double Walled/Secondary
Containment
F = Fiberglass
S = Coated or Bare Steel
F/S = FRP Clad Steel
STI = (STI- P3) Steel Tank Institute
T.P.
FRP = Single Walled Fiber
Reinforced Plastic
CP/S = Cathodically Protected
Steel
R = Relined
WS = Welded Steel
PL = Plastic
V = Vaulted
O = Other (Please Specify)
RG = Reg. Gasoline
UG = Unleaded Gas
D = Diesel
K = Kerosene
NO = New Oil
WO = Waste Oil
HO = Heating Oil
O = Other (Please
Specify)
C = Concrete
GR = Gravel
E = Dirt/ Earth
EPA = Other EPA/DEP
approved material
O= Other (Please Specify)
ATM = Auto Tank
Monitoring
GW = Groundwater Wells
SIA = Statistical Inventory
Analysis
IM = Interstitial Monitoring
TT = Tightness Tests**
**Show last test date and
indicate result – P/F
(Pass/Fail). Proof of
tightness test results must
be submitted to underwriter
Page 6 of 8
6. a. Are the pipes 100% above ground?
b. If no, have there been tightness tests
performed on the below ground
piping?
YES NO
YES NO (If yes, when?)
7. a. Have the Above Storage Tank bottoms been
relined?
b. If so how many times has tank been
relined?
c. Was the contractor a certified tank reliner?
d. Please provide the name of the certified
contractor and reason(s) why the relining
was performed:
YES NO
YES NO
8. a. Please provide a survey plat (blueprint) for this
facility. Above tanks may be subject to periodic
integrity testing per- 40 CFR 112.7 (e) (2).
b. Have these tanks recently been tested?
YES NO (If yes, when?)
9. Is any technology in place to prevent or detect a leak?
YES NO (If yes, please
identify)
10. Is there a history of leaks or releases at this
facility related to aboveground storage tanks?
YES NO (If yes, please describe
below)
11. Is the owner of the property the same as the
owner of the storage tanks?
YES NO (If no, please explain
the relationship of the tank owner to the
property owner.)
Page 7 of 8
V. GENERAL QUESTIONS
1. Have you during the last five years been
prosecuted, or are you currently being
prosecuted, for violations of any standard
or law relating to the release or threatened
release from the location of a regulated
substance, hazardous waste or any other
pollutant?
YES NO (If yes, please describe
below)
2. List all claims made against you during the
past five years for cleanup or response action,
regulated substances, or bodily injury or
property damage, resulting from the release of
regulated substances, hazardous waste or any
other pollutants, from this location or other
locations owned or operated by you, into the
environment. Provide a brief description of the
claim (s) and its disposition. If none, so state.
3. At the time of the signing of this application,
do you know of any facts or circumstances
which may reasonably be expected to result in
a claim being asserted against your company
for environmental cleanup or response, or for
bodily injury or property damage arising from
the release of a pollutants into the
environment? If none, so state.
4. a. Is there an SPCC plan in place?
b. Are regular inspections and
maintenance performed as specified in the
plan?
YES NO (If yes, please provide a
copy)
YES NO
Page 8 of 8
COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT’S
ACCEPTANCE OF COMPANY’S QUOTATION IS REQUIRED PRIOR TO BINDING
COVERAGE AND POLICY ISSUANCE. ANY PERSON WHO KNOWINGLY
INCLUDED ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION
FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL
PENALTIES.
THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS AND FACTS
ARE TRUE AND THAT NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR
MISSTATED.
IF AN ORDER IS RECEIVED, THE APPLICATION IS ATTACHED TO THE
POLICY, SO IT IS NECESSARY THAT ALL QUESTIONS BE ANSWERED IN
DETAIL.
APPLICANT Date:
(signature of owner or officer)
APPLICANT
(print name & title):
BROKER Date:
(print name of firm):
(address of brokerage firm):
(contact person & telephone number):
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STORAGE TANK APPLICATION This application is for single (Access E&S Insurance Services)

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Completed 8 January 2021

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