Non Environmental Contractors Pollution Liability Application Template
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4C&S S
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PECIALTY
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C&S S
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1100 C
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| T: 855.390.7598 | F: 678.999.5121 |
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COM
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CSUNDERWRITERS
COM
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NVIRONMENTAL
ONTRACTOR
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OLLUTION
IABILITY
UPPLEMENTAL
PPLICATION
This application is NOT an insurance policy and the insurance company affording coverage reserves the right to reject any application for any reason. If
additional space is needed, attach details on a separate sheet of paper. All Applicants must sign the application where indicated.
A Signed and Completed Acord 125 is required with this Supplemental Application
PRODUCER
APPLICANT
Name:
Name:
Address:
Address:
Telephone #:
Telephone #:
Fax #:
Fax #:
Email Address:
Email Address:
Website:
Website:
PRODUCER NAME:
PRIMARY CONTACT NAME:
Inspection Contact Name/Telephone:
D&B Number:
SECTION I. General Information
Specify the year that the Applicant initially commenced operations:
What are the Applicant’s total gross receipts for each of the last 3 years?
1st Preceding Year: $
2nd Preceding Year: $
3rd Preceding Year: $
Applicant’s Total Number of Employees:
_________ Employees
YES
NO
YES
NO
Has the Applicant ever in the past, currently or plan to in the future
Has any claim, suit or notice of incident been made
directly or indirectly perform any of the following operations: abatement,
within the last five years against the Applicant or
disposal, transportation, encapsulation, remediation, incineration,
reported under any CGL, CPL or PL policies? If yes,
mitigation, removal, excavation, containment, treatment, detoxification,
please provide the details on a separate sheet of
decontamination, neutralization of pollutants and/or related services,
paper.
including any consulting or professional services? If yes, provide more
details of these services on a separate sheet of paper.
Is the Applicant a successor of any other business? If
Does the Applicant, directly or indirectly work with any hazardous
yes, list details on a separate sheet
solid, liquid, gaseous, thermal, biological or radioactive substance,
Is Applicant, or any affiliated, related or predecessor
material or matter, irritant or contaminant including smoke, vapors,
entity currently involved in any litigation, administrative
soot, fumes, acids, alkalis, chemicals, waste or any other hazardous
or arbitration proceeding(s) or subject to any court or
materials during your operations? If yes, provide details of the
agency order or injunction? If yes, provide the detail
materials on a separate sheet of paper.
on a separate sheet of paper.
Are more than 25% of the Applicant’s services subcontracted? If
yes, provide a copy of the standard contract for underwriting review
Has the Applicant, or any affiliated, related or
predecessor entity or any officer or owner of any of
Are the Applicant’s subcontractors licensed and accredited?
them ever been convicted of a crime? If yes, describe
Is a standard written contract used with the Applicant’s clients and /or
on a separate sheet of paper.
subcontractors, including hold harmless and limitation of liability
Does the Applicant directly or indirectly perform non-
clauses? If yes, provide a copy of the standard contract for
environmental work on residential properties? What
underwriting review
percentage of work is residential?
Does the Applicant require minimum general liability insurance limits
___________________________________________
for its subcontractors? Required limit? __________________
Does the Applicant directly or indirectly perform
Does the Applicant directly or indirectly perform any work related to the
operations in New York State? If yes, what % of total
Oil/Gas industry including any pipeline services?
operations are performed in New York State? _____%
Does the Applicant directly or indirectly perform any operations involving
Is the coverage request for one specific project? If yes,
Exterior Insulation and Finishing Systems (EIFS)?
provide the Project Name, Location, Duration and Project
Description on a separate sheet of paper.
CSS NON ENV APP 12 14
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