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- SUPPLEMENTAL APPLICATION PREMISES ENVIRONMENTAL COVERAGE YOUR INSURED (Philadelphia Insurance Companies)

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- SUPPLEMENTAL APPLICATION
PREMISES ENVIRONMENTAL COVERAGE – YOUR INSURED LOCATION
SECTION I – GENERAL INFORMATION
Applicant Name:
Address of the location for which the Applicant is seeking Premises Environmental Coverage
(Complete a Premises Environmental Coverage Supplemental Application for each contiguous location to be insured)
Facility Name / ID
Address
City
State
Zip
Is this location:
Rented by the Applicant
Operated by the Applicant
Requested Limits and Deductibles
Per Incident Limit
Aggregate Limit
Deductible
Retroactive Date
$
$
$
$
$
$
$
$
$
ENVIRONMENTAL REPORTS
1.
Have any environmental site assessments (ESAs) been conducted at the proposed covered
location in the last 5 years?
Yes
No
2.
Is the location currently insured under any environmental liability coverage?
Yes
No
If yes, provide a copy of the Declarations, Policy and Endorsements.
SECTION II – USAGE AND OPERATIONS
1.
Briefly describe the relevant usage and operations that currently take place at the location:
2.
Does current usage and operations at the location include the treatment, storage or processing of
hazardous materials or potential pollutants?
Yes
No
If yes, please complete Section 5 of this Supplemental.
3.
Are there any storage tanks located at the property?
Yes
No
If yes, please complete Section 4 of this Supplemental.
4.
Are there any abandoned tanks, drums, or equipment at the location?
Yes
No
5.
Is any portion of the location currently used as habitational property?
Yes
No
If yes, please describe:
6.
Is there any anticipated future change in the use of the location?
Yes
No
If yes, please describe:
E-PAC Premises Environmental Coverage
Page 1 of 3
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
Clear Application
Print Application
7.
Is the future usage of the location anticipated to include treatment, storage or processing of
hazardous materials or other potential pollutants?
Yes
No
If yes, please complete Section 5 of this Supplemental.
8.
Is the location anticipated to be used for habitational purposes in the future?
Yes
No
If yes, please describe:
9.
Please describe the historical past uses of the location:
10.
Have dry cleaning operations ever been conducted at the facility?
Yes
No
11.
Have hazardous wastes or other potential pollutants ever been treated, stored or processed at the
facility?
Yes
No
If yes, please complete Section 5 of this Supplemental.
SECTION III – THIRD PARTIES AND RECEPTORS
1.
Describe the type and usage of the properties adjoining and in close proximity to the location:
2.
How close is the nearest surface water (pond, lake, ocean, stream or river)?
3.
Are there any potable water wells at the location?
Yes
No
If yes, is the water tested annually and does it meet all applicable local, state and federal
standards?
Yes
No
4.
Are there any 3
rd
party drinking wells located within ½ mile of the location?
Yes
No
5.
Is there a septic system on site at the location?
Yes
No
SECTION IV – STORAGE TANKS
1.
Identify all Storage Tanks currently at the location. Refer to KEY below – (List all that apply)
None
Tank
ID
UST
AST
Age
Size
(gallons)
Contents
Construction
Type
Leak
Detection /
Prevention
for UST’s
Containment
Piping
KEY
Contents:
(G) Gasoline, (D) Diesel, (F) Fuel Oil, (C) Crude Oil, (W) Waste Oil, (H) Hazardous Waste (O) Other
Construction Type:
(SWBS) Single Wall Bare Steel; (SWCP) Single Wall Steel with Cathodic Protection; (SWFG) Single
Wall Fiberglass or Synthetic Material; (DW) Double Walled
Leak Detection:
(IM) Interstitial Monitor (w/Containment); (VM) Vapor Monitoring; (GWM) Groundwater Monitoring;
(ATG) Automatic Tank Gauging Systems; (SIR) Statistical Inventory Reconciliation; (TTT) Tank
Tightness Testing w/ Inventory Control;
(M) Manual Gauging; (LLD) Line Leak Detectors
Containment:
(DW) Double Wall Tank; (C) Concrete; (IB) Impermeable Barrier – Other; (S) Native or Amended Soils
Piping:
(DW) Double Wall; (SWP) Single Wall Pressure Pumping; (SWS) Single Wall Suction Pumping
2.
Has a licensed environmental professional designed or assessed the Applicant’s tank system(s) to
be compliant with all relevant environmental regulations applicable to the Applicant’s jurisdiction?
Yes
No
E-PAC Premises Environmental Coverage
Page 2 of 3
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
Clear Application
Print Application
SECTION V – WASTE AND MATERIALS
1.
Identify all raw materials, wastes or chemicals stored, treated or transferred through the location.
None
Waste, Materials or
Chemicals
Quantity Stored
(at any one time)
Method of Storage
(pallet, drum, container)
Treatment, Discharge or
Disposal Method
2.
Does the Applicant store all reactive and / or incompatible materials separately from one another?
Yes
No
3.
Are the Applicant’s hazardous materials stored in a dedicated area with an impermeable floor?
Yes
No
4.
Does the location require a permit for any waste handling, storage or disposal practices?
Yes
No
If yes:
a.
Is the facility in compliance with all permit requirements?
Yes
No
b.
Please submit a copy of the relevant permits as part of the application process.
SECTION VI - MOLD
1.
Is the Applicant seeking coverage for mold related pollution conditions at the location?
Yes
No
2.
In what year was the facility built?
3.
Describe the construction type used for the buildings and improvements on the location:
4.
Does the Applicant have a facility maintenance program that includes protocols for:
a.
Regular inspection and maintenance of the HVAC system(s) on the site?
Yes
No
b.
Moisture, mold and water intrusion inspections and prevention?
Yes
No
5.
Are there any tenants at the location that rent space from the Applicant? If yes, please describe:
Yes
No
6.
Have there been any mold-related incidents, claims, or losses at the location?
Yes
No
SECTION VII – LOSS CONTROL AND RISK MANAGEMENT
1.
Does the facility operate under written environmental risk management / control procedures?
Yes
No
Please check all that apply, and / or describe “Other” categories:
Generic Environmental Risk Management Plan
Spill Prevention, Control, and Countermeasure (SPCC)
Anhydrous Ammonia Operating & Safety Procedures
Haz Mat Operations & Emergency Response Plan
Environmental Compliance Assurance Audits
Hazard Communication Program
Other:
Other:
2.
Is there a trained / qualified individual(s) responsible for managing the environmental site risks?
Yes
No
This application is to be used in conjunction with a completed E-PAC Primary Application. 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
_______________________________________________
APPLICANT: (Signature of Owner of Officer of corporation)
Date
APPLICANT: (Print Name and Title)
E-PAC Premises Environmental Coverage
Page 3 of 3
© 2019 Philadelphia Consolidated Holding Corp.
08/2019
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Completed 7 November 2020

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