Pollution Insurance

Instructions:

Please type or print clearly. Answer ALL questions completely, leaving no blanks. If any questions, or part thereof, do not apply, print "N/A" in the space. Provide any supporting information on a separate sheet using the Applicant's letterhead and reference the applicable question number. Check Yes or No answers. This form must be completed, dated and signed by an authorized representative of the Applicant. Required Attachments: Please provide copies of the Applicant's past two (2) years of audited financial statements and annual reports. Summary of Environmental Site Assessments/Remediation (past, current, planned)

Other Required Attachments

Tank Inventory List (Check here if not applicable)
Permit Schedule (Check here if not applicable)

Notice to Applicant:

THE COVERAGE APPLIED FOR IS SOLELY AS STATED IN THE POLICY AND ANY ENDORSEMENT THERETO. THE POLICY PROVIDES LIABILITY COVERAGE ON A CLAIMS-MADE AND REPORTED BASIS, WHICH COVERS ONLY CLAIMS FIRST MADE AGAINST AN INSURED AND REPORTED TO THE INSURER, IN WRITING, UDRING THE POLICY PERIOD. THE POLICY ALSO PROVIDES COVERAGE FOR REMEDIATION COSTS ON A DISCOVERED AND REPORTED BASIS, WHICH COVERS ONLY POLLUTION CONDITIONS FIRST DISCOVERED AND REPORTED TO THE INSURER, IN WRITING, DURING THE POLICY PERIOD.

Name of Applicant

First Last

Principal Contact

Email

Principal contact regarding mold, asbestos, and lead health and safety issues:

Mailing Address

Street Address Address Line 2 City State ZIP Code

Phone

Fax

Website

Date

The applicant is

Subsidiary, predecessor, acquired parent, affiliated, or merged firms for which coverage is requested:

Name of firm	Date of formation or transaction	# of professional staff that joined the insured	% of firm annual billings assigned to the insured

Details of covered locations

Company name	Street address city, state zip code	Standard industrial classification code sic	Year operations began	Facility size (acres or square feet)	Known pre-exsisting contamination present?

Upload details

If "Yes" is indicated above with respect to Known Pre-Exsisting Contamination Present, Please provide details on a separate sheet. Include at a minimum:

Prior Environmental site Assessments (dates)
Past, Current, Planned sampling/remediation; etc.

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 200 MB.

Please provide the estimated sales associated with the following activities beyond the boundaries of the covered location(s) for the current fiscal year

Under the "Activity" field please add all the items that apply. Below are examples of "Activities".
Property Management
Pipeline Installation
Pipeline/sewer/septic maintenance
Industrial cleaning
Hydroblasting
Demolition
Electrical
HVAC
Plumbing
Water/sewer
Road Construction/ Maintenance
Excavation
Site Development/grading
Concrete work
General Construction
Other (explain)

Activity	Sales	% Sub-Contracted

Sales Total

Please add all the Sales Total fields together and add the total here.

% Sub-Contracted Total

Please add all the % Sub-Contracted fields together and add the total here.

Does the Applicant have a standard contract to use with its subcontractors?

Yes
No

If "Yes" is indicated above, do they contain hold harmless or indemnification agreements in favor of the Applicant and other affiliated parties to the proposed insurance?

Yes
No

If applicable, what are the Applicant's, other affiliated parties' and foreign subsidiaries' minimum insurance requirements for subcontractors?

General Liability $	Auto $	Contractors pollution liability $	Not Applicable

Applicant's total gross revenues as filed in its latest tax return, excluding recovered expenses

$ for the period ending	Month	Year

Applicant's estimated gross revenues for the current fiscal year

Applicant's estimated gross revenues for contracting operations for the current fiscal year

Desired Effective date of coverage

Limits of Liability

Per Pollution Condition $	Aggregate $

Self-Insured Retention

Per Pollution Condition $

Within the past five (5) years has the applicant, any other party to this insurance, or any foreign subsidiary purchased this type of insurance coverage?

Yes
No

Upload Details

If "yes" is indicated above, please provide detailed information regarding any such coverage and all available loss information as an attachment to this application

Max. file size: 200 MB.

Within the past five (5) years have any claims been made or legal actions (including any regulatory proceedings) been brought against the Applicant, any other party to the proposed insurance, or any foreign subsidiary?

Yes
No

Does the applicant, any other party to the proposed insurance or any foreign subsidiary have knowledge of any pollution conditions at any of the proposed covered locations?

Yes
No

Does the Applicant, any other party to the proposed insurance, or any foreign subsidiary have knowledge of injury to people or damage to the property during the last five (5) years resulting from the transportation of the Applicants, any other party's, or any foreign subsidiary's waste, goods or products?

Yes
No

Does the Applicant, any other party to the proposed insurance, or any foreign subsidiary have knowledge of any claims made or pollution conditions discovered during the last five (5) years resulting from the transportation of the Applicant's, any other party's or any foreign subsidiary's waste is currently being, or has historically been, taken for recycling or disposal?

Yes
No

Does the Applicant, any other party to the proposed insurance, or any foreign subsidiary have knowledge of any claims made with respect to pollution conditions on, at, under or migrating from, any disposal sites to which the applicant's, any other party's or any foreign subsidiary's waste is currently, or has the historically been taken for recycling or disposal?

Yes
No

At the time of signing this application, is the Applicant, any other party to the proposed insurance or any foreign subsidiary aware of any circumstances that may reasonably be expected to give rise to claim against the applicant, any other party to the proposed insurance or any foreign subsidiary from the release of pollutants?

Yes
No

Upload Details

If "yes" is indicated with respect to questions above, please provide a detailed description of the claim or circumstance (indicate the alleged incident, location, date, type of injury, etc.) Also, please provide a summary of any steps that may have been taken to avoid or mitigate the possibility of similar loss occurring in the future.

IT IS UNDERSTOOD AND AGREED THAT IF ANY SUCH CLAIMS EXIST, OR ANY SUCH FACTS OR CIRCUMSTANCES EXIST WHICH COULD GIVE RISE TO A CLAIM, THEN THOSE CLAIMS AND ANY OTHER CLAIMS ARISING FROM SUCH FACTS OF CIRCUMSTANCES ARE EXCLUDED FROM THE PROPOSED INSURANCE UNLESS OTHERWISE AFFIRMATIVELY STATED IN THE POLICY.

Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 200 MB.

If you are not, please confirm that the items below are not applicable by checking here

N/A

Are all of the storage tanks to be covered pursuant to this insurance (hereinafter storage tanks) complaint with all applicable federal, state, provincial, and local laws and regulations?

Yes
No

If "No" is indicated above, please provide a written explanation of outstanding compliance issues as an attachment to this application.

Are any of the Storage Tanks to located within the state of Florida

Yes
No

if the Applicant answered "yes" to question above, are any of the Florida-based storage tanks single walled storage tanks (i.e. bare steel tanks, steel tanks with cathodic protection, STIP 3/4 tanks or tanks opperating under ACT 100), Regardless of whether such single walled storage tanks have any form of tank lining?

Yes
No

Have any other storage tanks been removed or closed-in-place in the locations where the storage tanks are currently situated?

Yes
No

If "Yes" is indicated above, please provide detailed information identifying the specific storage tanks to be covered pursuant to this insurance, which are situated at the common location.

Will any of the storage tanks be removed, closed or upgraded within the next eighteen (18) months?

Yes
No

Supplemental information for Lead-Based Paint and Asbestos Coverage

If you are seeking coverage for liability arising out of bodily insury or property damage resulting from exposure to Lead-Based Paint and/or Asbestos, complete the following.

If you are not, please confirm that thte items below are not applicable by checking here

N/A

Do any of the buildings located at the proposed covered locations contain lead-based paint?

Yes
No

If the Applicant answered "yes" to the above does the applicant, any other relevant party to the proposed insurance, or any relevant foreign subsidiary have a lead-based paint management plan in place to address the lead-based paint?

Yes
No

Details Upload

If "yes" is indicated above, please provide a copy of any such plan(s) as an attachment to this application.

Max. file size: 200 MB.

Do any of the buildings located at the proposed covered locations contain asbestos or asbestos-containing materials (ACM)

Yes
No

If the Applicant answered "yes" above, does the applicant, any other relevant party to the proposed insurance, or any relevant foreign susidiary have an asbestos management plan in place to address the asbestos?

Yes
No

Details Upload

If "yes" is indicated above, please provide a copy of any such plan(s) as an attachment to this application

Max. file size: 200 MB.

Have any health concerns been raised, or any claims been made, with respect to the presence of lead-based paint, asbestos or asbestos-containing materials at any of the buildings located at the proposed covered locations?

Yes
No

Details Upload

If "yes" is indicated above, please provide detailed information regarding the health concerns and/or claims as an attachment to this application

Max. file size: 200 MB.

UNDERSTOOD AND AGREED

IT IS UNDERSTOOD AND AGREED THAT IF ANY SUCH CLAIMS EXIST, OR ANY SUCH FACTS OR CIRCUMSTANCES EXIST WHICH COULD GIVE RISE TO A CLAIM, THEN THOSE CLAIMS AND ANY OTHER CLAIMS ARISING FROM SUCH FACTS OR CIRCUMSTANCES ARE EXCLUDED FROM THE PROPOSED INSURANCE UNLESS OTHERWISE AFFIRMATIVELY STATED IN THE POLICY.

Supplemental information for Mold, Fungi and/or Legionella Pneumophila coverage

If you are seeking coverage for Mold, Fungi, and/or Legionella Pneumophila, complete the following.

If you are not please confirm that the items below are not applicable by checking here

N/A

Do the applicant, any other parties to the proposed insurance, and any foreign subsidiaries perform due diligence with respect to mold and/or fungi when acquiring or leasing property such as in accordance with ASTM standard E2418-06 "standard guide for Readily Observable Mold and Conditions Conductive to Mold in Commercial Buildings: Baseline Survey Process?"

Yes
No

Details Upload

If "yes" is indicated above, please provide detailed information regarding the scope of that due diligence as an attachment to this application.

Max. file size: 200 MB.

Have any of the buildings located at the proposed covered locations ever been identified as having mold, fungi, legionella pneumophila or similar bacteria-related problems?

Yes
No

Details Upload

If "yes" is indicated above, please provide detailed information regarding the scope of that due diligence as an attachment to this application.

Max. file size: 200 MB.

Have any of the buildings located at the proposed covered locations eperienced any water leaks or flooding within the past five (5) years.?

Yes
No

Details Upload

If "yes" is indicated above, please provide detailed information regarding the leaks for flooding as an attachment to this application.

Max. file size: 200 MB.

Have any of the buildings located at the proposed covered locations constructed using Exterior Insulation and Finish Systems (EFIS)?

Yes
No

Details Upload

If "yes" is indicated above, please provide detailed information confirming the applicable locations as an attachment to this application.

Max. file size: 200 MB.

Do the Applicant, any other parties to the proposed insurance, and any foreign subsidiaries have mold management and/or water intrusion plans in place with respect to the proposed covered locations?

Yes
No

Details Upload

If "yes" is indicated above, please provide a copy of any such plan(s) as an attachment to this application.

Max. file size: 200 MB.

Do employees or members of the Applicant, any other parties to the proposed insurance, and any foreign subsidiaries receive training regarding the handling of mold, fungi, or legionella pneumophila or similar bacteria-related issues?

Yes
No

Details Upload

If "yes" is indicated above, lease provide detailed information regarding such training as an attachment to this application.

Max. file size: 200 MB.

Have any health concerns been identified by, or any claims been made against, the Applicant, any other parties to the proposed insurance, or any foreign subsidiaries with respect to mold, legionella pneumophila, similar bacteria-related issues or any other indoor air quality-related issues at buildings located on any of the proposed covered locations

Yes
No

If "Yes" is indicated above, please provide a brief description of the claim or circumstance( indicate the alleged incident, location, date, type of injury, etc.) also, please provide a summary of any steps that may have been taken to avoid or mitigate the possibility of a similar loss occurring in the future.

UNDERSTOOD AND AGREED

*IT IS UNDERSTOOD AND AGREED THAT IF ANY SUCH CLAIMS EXIST, OR ANY SUCH FACTS OR CIRCUMSTANCES EXIST WHICH COULD IVE RISE TO A CLAIM, THEN THOSE CLAIMS AND ANY OTHER CLAIMS ARISING FROM SUCH FACTS OR CIRCUMSTANCES ARE EXCLUDED FROM THE PROPOSED INSURANCE UNLESS OTHERWISE AFFIRMATIVELY STATED IN THE POLICY.

BY SIGNING THIS APPLICATION, THE APPLICANT WARRANTS TO THE INSURER THAT IT AND THE OTHER PARTIES TO THIS INSURANCE, ALONG WITH ANY FOREIGN SUBSIDIARIES, WILL STRICTLY FOLLOW ANY WATER INTRUSION, MOLD-RELATED, FUNGI-RELATED OR BACTERIA-RELATED OPERATION AND MAINTENANCE PROCEDURES OR PROTOCOLS, INCLUDING ANY WATER INTRUSION, MOD RELATED, FUNGI-RELATED OR BACTERIA-RELATED DUE DILIGENCE PROCEDURES AND PROTOCOLS FOR THE ACQUISITION, LEASE, OPERATION, MANAGEMENT OR MAINTENANCE OF ANY PROPERTIES, WHICH WERE PROVIDED TO THE INSURER PRIOR TO THE INCEPTION OF ANY COVERAGE APPLIED FOR HEREIN. THE APPLICANT ACKNOWLEDGES THAT THE INSURERS AGREEMENT TO PROVIDE MOLD, FUNGI, AND/OR LEGIONELLA PNEUMOPHILA COVERAGE AS PART OF THE COVERAGE APPLIED FOR PURSUANT TO THIS APPLICATION IS PREDICATED UPON THE APPLICANT'S AGREEMENT TO PROVIDE THIS WARRANTY.

BY SIGNING THIS APPLICATION, THE APPLICANT WARRANTS TO THE INSURER THAT IT AND THE OTHER PARTIES TO THIS INSURANCE, ALONG WITH ANY FOREIGN SUBSIDIARIES, WILL STRICTLY FOLLOW ANY LEAD-BASED PAINT OR ASBESTOS OPERATION AND MAINTENANCE PROCEDURES OR PROTOCOLS, WHICH WERE PROVIDED TO THE INSURER PRIOR TO THE INCEPTION OF ANY SUCH COVERAGE APPLIED FOR HEREIN. THE APPLICANT ACKNOWLEDGES THAT THE INSURER'S AGREEMENT TO PROVIDE LEAD-BASED PAINT AND/OR ASBESTOS COVERAGE AS PART OF THE COVERAGE APPLIED FOR PURSUANT TO THIS APPLICATION IS PREDICATED UPON THE APPLICANT'S AGREEMENT TO PROVIDE THIS WARRANTY.

BY SIGNING THIS APPLICATION, THE APPLICANT WARRANTS TO THE INSURER THAT ALL STATEMENTS MADE IN THIS APPLICATION, INCLUDING ANY ATTACHMENTS THERETO, ABOUT THE APPLICANT AND ITS OPERATIONS ARE TRUE AND COMPLETE, AND THAT NO MATERIAL FACTS HAVE BEEN MISSTATED IN THIS APPLICATION OR CONCEALED. COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. THE APPLICANT'S ACCEPTANCE OF THE INSURER'S QUOTATION IS REQUIRED BEFORE THE APPLICANT MAY BE BOUND AND A POLICY IS ISSUED.

NOTICE TO APPLICANTS: any person who knowingly presents a false or fradulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime may be subject to fines and confinement in prison.

NOTICE TO ARKANSAS, LOUISIANA, RHODE ISLAND and WEST VIRGINIA APPLICANTS: any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO COLORADO APPLICANTS: it is unlawful to knowingly provide false, incomplete, or misleading facts or information to an 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 with the Department of Regulatory Agencies.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: it is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition an insurer may deny insurance benefits if false information materially related to a claim was provided by the Applicant.

NOTICE TO FLORIDA APPLICANTS: 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.

NOTICE TO KENTUCKY APPLICANTS: 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.

NOTICE TO MAINE APPLICANTS: it is a crime to knowingy provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment for a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MINNESOTA APPLICANTS: A person who submits an application for files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

NOTICE TO NEW JERSEY APPLICANTS: any person who includes any false or misleading information on an application for an insurance policy is subject to criminal ad civil penalties.

NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NOTICE TO NEW YORK APPLICANTS: 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 also be subject to a civil penalty not to be exceed five thousand dollars and the stated value of the claim for each violation.

NOTICE TO OHIO APPLICANTS: any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: any person who knwoingly, and with intent to injure, defraud, or deceive any insurer, makes a claim for the proceeds of an insurance policy containing any false incomplete or misleading information is guilty of a felony.

NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: 1) by submitting an application, or 2) by filing a claim containing a false statement as to any material fact may be a violating state law. NOTICE TO PENNSYLVANIA APPLICANTS: 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. NOTICE TO TENNESSEE, VIRGINIA, and WASHINGTON APPLICANTS: it is a rime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Instructions:

Notice to Applicant:

Supplemental information for Lead-Based Paint and Asbestos Coverage

UNDERSTOOD AND AGREED

Supplemental information for Mold, Fungi and/or Legionella Pneumophila coverage

UNDERSTOOD AND AGREED

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