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«THIS IS AN APPLICATION FOR A CLAIMS-MADE POLICY. IN ADDITION TO OTHER LIMITATIONS ON COVERAGE, PAYMENT OF LEGAL EXPENSE REDUCES THE LIMIT OF ...»

-- [ Page 1 ] --

Chubb Group of Insurance Companies

APPLICATION FOR

ENVIRONMENTAL SITE

LIABILITY POLICY

15 Mountain View Road, Warren, New Jersey 07059

THIS IS AN APPLICATION FOR A CLAIMS-MADE POLICY. IN ADDITION TO OTHER LIMITATIONS

ON COVERAGE, PAYMENT OF LEGAL EXPENSE REDUCES THE LIMIT OF INSURANCE.

PLEASE READ THE POLICY CAREFULLY.

For purposes of this application, “you” and “your” refer to the named insured designated below and any officer, partner, director, manager or member thereof.

PLEASE PROVIDE THE FOLLOWING DOCUMENTS AND MATERIALS ALONG WITH THE COMPLETED

ORIGINAL SIGNED AND DATED APPLICATION. ONCE THIS APPLICATION IS RECEIVED, A MEMBER OF

OUR STAFF MAY TELEPHONE THE SITE CONTACT DESIGNATED BY YOU IN THE ATTACHED SITE CONTACT

SCHEDULE TO CONDUCT A TELEPHONE SURVEY AS PART OF THE APPLICATION PROCESS. THE

ATTACHED TELEPHONE SURVEY SUMMARIZES THE INFORMATION THAT WILL BE REQUESTED AND

SHOULD BE PROVIDED TO SUCH CONTACT PERSON.

Please provide the following documents and materials along with the completed original signed and dated application:

• Audited financials and/or 10K for the latest three (3) years.

enclosed information to follow do not exist • Schedule of environmental insurance policies for the past three (3) years.

enclosed information to follow do not exist • Environmental surveys/audits, risk assessments, Phase I’s, Phase II’s, Phase III’s conducted for any site for which this application is being made.

enclosed information to follow do not exist

A. GENERAL INFORMATION

1. Named Insured: __________________________________________

Address: __________________________________________

__________________________________________

__________________________________________

Telephone: __________________________________________

Fax: __________________________________________

Email: __________________________________________

2. Names Insured is a: Corporation Partnership Joint Venture Other _________________

3. Describe in detail the Named Insured’s operations: _____________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

4. List all other insureds requesting coverage under this policy and describe the relationship to the Named Insured:

–  –  –

________________________________________ _______________________________________

________________________________________ _______________________________________

________________________________________ _______________________________________

________________________________________ _______________________________________

–  –  –

1. During the past five (5) years have you been, or are you currently being prosecuted for any violation of any standard or law relating to the release or threatened release of any hazardous substance or pollutant at or from

any site into the environment? Yes No. If yes, describe in detail:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

2. During the past five (5) years have there been any reportable discharges or releases of any hazardous substance

or pollutant at or from any sites for which this application is being made? Yes No. If yes, describe in detail:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

3. During the past five (5) years have there been any claims made against you resulting from the actual or alleged release of any hazardous substance or pollutant at or from any site for which this application is being made?

Yes No. If yes, describe in detail:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

4. Are you aware of any fact or circumstance that could reasonably be expected to result in a claim being made against you arising from the release of any hazardous substance or pollutant into the environment?





Yes No. If yes, describe in detail:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

–  –  –

Limits of Insurance Requested: (may request multiple options) a. Each Pollution Incident $ ___________________________________________________________

–  –  –

Deductible Requested: (may request multiple options) $ _____________________________________________

Existing Pollution or Environmental Insurance Coverage

–  –  –

c. State the retroactive date of inforce claims-made coverage: _______________________________________

Page 2 of 7

D. ENVIRONMENTAL MANAGEMENT AND COMPLIANCE

1. Manager/employee responsible for environmental matters: ________________________________________

2. Describe the environmental duties of the manager/employee responsible for environmental matters: _______ ______________________________________________________________________________________

______________________________________________________________________________________

3. Are there on-going remediation projects at any proposed insured site? Yes No. If yes, describe: _____ ______________________________________________________________________________________

______________________________________________________________________________________

4. Is there existing contamination at any proposed insured site? Yes No. If yes, describe: ____________

______________________________________________________________________________________

______________________________________________________________________________________

E. INSURED SITE INFORMATION

1. Describe the physical operations including year built for the buildings/facilities at each proposed insured site:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

2. Describe previous occupancies and/or land use for each proposed insured site:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

3. Describe the surrounding environment (one mile radius) of each proposed insured site, including topography, land use, waterways, types of industries, residences, schools, hospitals, etc.

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

4. Describe any on-site waste disposal activities (i.e. landfill, ponds, surface impoundment, lagoons, septic system,

leach fields, solvent recovery, incineration, etc.) at each proposed insured site:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

5. Describe off-site waste disposal processes, including:

Type of material, annual quantity, name and address of storage, transfer, disposal or recycling facility; and transportation of waste including: by whom, type of material and amount transported, number of trips per year,

distance per trip:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

6. Indicate any environmental permits applicable at any proposed insured site and if in compliance with same. If not

in compliance, provide details:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

7. Describe groundwater monitoring at all proposed insured sites. Indicate number of wells and provide results from most recent four (4) sampling events along with map showing the location of wells and groundwater flow

direction:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

–  –  –

1. For each proposed insured site, provide the following information. Clearly identify the insured site at which each

tank is located:

–  –  –

Page 4 of 7 By signing below, applicant hereby certifies that the statements made and the information and data supplied herewith are true, accurate and complete.

COMPLETION OF THIS APPLICATION DOES NOT BIND COVERAGE. APPLICANT’S ACCEPTANCE OF THE

COMPANY’S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE.

CERTIFICATION

The undersigned persons declare that to the best of their knowledge the statements set forth above and in any attachments or supplements to this APPLICATION are true and correct, and that every reasonable effort has been made to obtain sufficient information to facilitate the proper and accurate completion of this APPLICATION. The undersigned agree that if any significant change in the condition of the Applicant is discovered between the date of this APPLICATION and the effective date of the policy which would render this APPLICATION inaccurate or incomplete, notice of such change will be reported in writing to the COMPANY immediately and, if necessary, any outstanding quotation may be modified or withdrawn.

The undersigned persons understand and further agree that the completion and signing of this APPLICATION neither binds the COMPANY to sell nor the Applicant to purchase the insurance.

PLEASE NOTE: ONLY DULY APPOINTED AGENTS OF THE COMPANY AND LICENSED BROKERS ARE AUTHORIZED

TO SOLICIT APPLICATIONS FOR COVERAGE. AGENTS AND BROKERS ARE NOT AUTHORIZED TO BIND

COVERAGE. NO COVERAGE SHALL BE PROVIDED UNLESS THE COMPANY ACCEPTS THE APPLICATION AND

BINDS THE COVERAGE.

False Information:

Any person who, knowingly and with intent to defraud an insurance company or other person, files an Application or insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime.

False Information (California Only):

For your protection, California law requires the following to appear on this form:

Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

False Information (Colorado Only):

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.

False Information (Florida Only):

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 of the third degree.



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