Non Environmental Contractors Pollution Liability Application Template Page 2

ADVERTISEMENT

Does Applicant, directly or indirectly, handle, transport and/or dispose of hazardous materials or substances? YES
NO
Please describe the hazardous substances the Applicant, directly or indirectly, handles or comes in contact with during its operations? Provide details on
a separate sheet of paper.
What Procedure does the Applicant employ in the disposal and transportation of hazardous materials/substances?
YES
NO
YES
NO
YES
NO
YES
NO
Bagged
Manifested
Transported
Labeled
Drummed
Stored
Treated On-Site
SECTION II. Retention, Limit & Coverage Requested
Effective Date:
Policy Term:
One Year
Other _______________
Coverage(s) Requested:
Occurrence
Claims-Made
Retro Date(If Claims Made)
Contractors Pollution Liability (CPL):
Transportation Pollution Liability
YES
NO
______________ _
Retention Type:
Self-Insured Retention
Deductible
Limits of Liability (Up to $5M):
Retention Amount:
$2,500
$5,000
$10,000
$25,000
Other_______
$1M/$1M
$1M/$2M
$2M/$2M
Other _____
Retention Amounts Above $10,000 are SIR only.
SECTION III. Contracting Services
General Contractor (Non-Environmental):
Carpentry
$
%
%
Carpet Cleaning
$
Concrete Construction
$
%
Construction Debris Removal
$
%
Demolition – Non-Structural (Interior Remodel)
$
%
Demolition – Over Two Stories
$
%
Demolition – Two or Less Stories
$
%
Dewatering
$
%
%
Door & Window Installation (excl. Mold)
$
Drilling – Non-Environmental
$
%
Electrical
$
%
Excavation/Grading
$
%
Fire/Water Restoration
$
%
F/W Debris Removal
$
%
General Construction
$
%
HVAC (excl. Mold)
$
%
%
Industrial Cleaning
$
Insulation
$
%
Janitorial
$
%
%
Painting
$
%
Plumbing
$
Remodeling
$
%
Roofing – Commercial
$
%
Roofing – Residential
$
%
%
Septic System Installation
$
Service Station Construction and Maintenance
$
%
Underground Utility Installation
$
%
Utility Installation Services
$
%
Waterproofing
$
%
%
Weatherization Services
$
Other (please specify)
%
$
Other (please specify)
$
%
Other (please specify)
%
$
Total Gross Receipts for Contracting Services:
$
CSS NON ENV APP 12 14
Page 2 of 4

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Non-union Bi-weekly Time Card Template Non-union Bi-weekly Time Card Template Business
Non-exempt Wage Employee Time Sheet Template Non-exempt Wage Employee Time Sheet Template Business
Contractors General Liability Supplemental Application/worksheet Contractors General Liability Supplemental Application/worksheet Business
Contractors General Liability Supplemental Questionnaire Template Contractors General Liability Supplemental Questionnaire Template Life
Contractor Credit Account Application - American Building And Roofing Contractor Credit Account Application - American Building And Roofing Business
Contractor Registration / Listing Application Contractor Registration / Listing Application Life
Contractor's Daily Report Template Contractor's Daily Report Template Business
Non-criminal Justice Requisition For Applicant Fingerprint Cards And Forms - North Carolina Bureau Of Investigation Non-criminal Justice Requisition For Applicant Fingerprint Cards And Forms - North Carolina Bureau Of Investigation Legal
Liability Application For Pest Control Program Liability Application For Pest Control Program Business
Application Template For Renewal Of Trademark, Service Mark, Certification Mark Or Collective Mark - Minnesota Secretary Of State Application Template For Renewal Of Trademark, Service Mark, Certification Mark Or Collective Mark - Minnesota Secretary Of State Legal

Related Categories

Parent category: Business
Download
Go
Page of 4