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Contractors and Consultants
Pollution Liability Application

Instructions

1. Please answer all questions. If any section does not apply, please indicate N/A.
2. If space is insufficient, attach additional sheets of paper or utilize blank sheet at the end of the application.
3. Have this application signed and dated by an authorized owner, partner, director or risk manager of the proposed first Named Insured. For purposes of this application, Applicant shall mean the person or entity making application for insurance and shall be deemed to include any person or entity proposed for insurance. Application shall also be deemed to include other persons or entities for which a proposed insured may be held legally liable including but not limited to an insured while acting within the scope of his or her durties for the proposed isured.
4. Attach a list of Names Insured(s) to be covered under this policy and the relationship to the Applicant.
5. The following items must be included for a complete submission:
A. This application
B. Most recent two years of audited financial statements
C. Currently valued general liability, contractor's pollution liability and professional liability loss runs for the past five years.
D. Resumes/Licenses/Certifications of key personnel
E. Brochures/Statements of qualifications
F. Project list - including the ten largest jobs initiated in the last three years.
G. Sample contract for use with clients, subcontractors, and subconsultants.
H. If project specific, standard operating procedures (SOP)

Please indicate which coverage you are seeking:
Contractors Pollution Liability (CPL) only
Combined CPL and Professional Liablity (PEC)
Professional Liability (E&O) only
Environmental Services Policy (ESP-Combined GL , CPL, E&O)

I - Applicant

Your Email

(REQUIRED)

Name insured

Address

2 - Street

2 - City

2 - State

2 - Zip

Contact name and title

Telephone number

Fax number

Web address

Requested effective date of coverage

How many years has the Applicant been in business?

How many years has the Applicant performed environmental services?

Named insured is

Partnership

Corporation

Joint venture

Other, please describe below

If Other, please describe

Is the applicant directly or indirectly associated with, controlled by, or owned by any other person or entity?

Yes No

If Yes, please describe

Does Applicant directly or indireclty own, control, or have liability for any other person or entity?

Yes No

If Yes, please describe

Has the Applicant's name or form of business entity changed, or has any other person of entity been purchased by, merged with, or consolidated into the Applicant?

Yes No

If Yes, please detail changes in chronological order.

II - Coverage Information

Requested limits of liability:

Each claim limit $

Aggregate limit $

Deductible $

Please list your current liability coverage information

Coverage	Carrier	Premium	Limits
Contractors pollution
General liability
Professional Errors and Ommissions
Contractor Pollution and Professional

Coverage	Expiration	Deductible or SIR	Retroactive date or Occurrence
Contractors pollution
General liability
Professional Errors and Ommissions
Contractor Pollution and Professional
III - Exposure History
	Year	Revenue ($)	Payroll ($)
Current / Projected
Expiring
First Prior Year
Second Prior Year
Third Prior Year
	Employees (#)
Current / Projected
Expiring
First Prior Year
Second Prior Year
Third Prior Year
V - Operations
What is the geographical extent of the Applicant's operations? Please provide the state/country, where services are performed and associated percentage of revenue.
State / County	Services Performed	Percent of Revenue (%)

Please describe any operations or services that have been discontinued, sold or abandoned, or any operations that have bee acquired.

Does the Applicant own, operate or lease a water treatment, storage, or disposal facility?

Yes No

Does the Applicant recommend, select, or arrange for the treatment, storage or disposal of materials?

Yes No

Does the Applicant or any other person or organization for whom the Applicant is or may be liable engage now or in the past in:

1 - Design/build activities?

Yes No

2 - Manufacture, sale, leasing, or distribution of any product?

Yes No

3 - Real estate development?

Yes No

4 -Development, design, redesign, or leasing computer software or equipment or provide computer consulting activities?

Yes No

5 - Waste management or waste brokering activities?

Yes No

Have there been any significant changes in busines strategy over the past year?

Yes No

Have there been any significant changes in management over the past year?

Yes No

Is the Applicant providing any services not provided last year?

Yes No

Has the Applicant filed for bankruptcy in the last five years?

Yes No

If 'yes' was answered for any of the above questions please describe:

VI - Breakout of operations

27 - Please indicate the approximate percentage of your total gross revenues derived from the following categories of clients

Category	Percent
Commercial
Contractors, Architects, Engineers or Environmental Consultants
Industrial
Federal government
State government
Local government
Real estate development
Lending institutions
Owners who act as their own contractors
Educational / Institutional
Other (specify)

What percentage of your work is with repeat customers?

28 - Column A is the dollar value of Gross Receipts
Column B is the percent of Gross Receipts Subcontracted
Column C is the dollar value of Payroll

	A	B	C
Environmental contracting
Remediation
Bio remediation
Dredging
PCB Handling
Soil Excavation
Soil/Groundwater Treatment
Other Remediation (explain below)

Subsurface activities
Pipeline construction
Sewer/Septic services
UST installation, removal and cleaning
Other subsurface (explain below)

Industrial maintenance
Above-ground tank cleaning
Hydroblasting
Other industrial Maintenance (explain below)

Mobile Operations
Incineration
Wasterwater Treatment
Other Mobile Operations (explain below)

Asbestors and Lead
Asbestos abatement
Lean abatement - commercial
Lean abatement - residential
Mold Abatement (complete supplemental mold application)
Mold abatement - commercial
Mold abatement - residential
Fire, Smoke, Water Damage Restoration (complete supplemental mold application)
Water extraction/drying - commercial
Water extraction/drying - residential
Miscellaneous
Electrical / HVAC / Plumbing
Emergency response
General construction
Lab packing
Soil / Well / Ground water boring
Storage and disposal
Supervision and oversight
Non-environmental contracting MIscellaneous
Carpentry NOC
Dry wall or wallboard installation
Electrical
General Contractor - CM - commercial
General Contractor - CM - residential
Heating and/or heating and air conditioning
Insulation work - mineral
Insulation work - organic or plastic
Insulation work - plastic - NOC
Paving, grading, landscaping, street & road
Painting interior - buildings or structures
Plumbing - commercial and industrial
Roofing
Siding and window installation
Wrecking (three stories or less)
Other (explain below)

Total (all above categories)

Professional Services
Environmental assessments
Environmental consulting
Environmental engineering
Geotechnical (CA & FL)
Geotechnical (all other states)
Lab packing
Mold assessment (complete supplemental mold application)
Mold investigation (complete supplemental mold application
Mold remediation (complete supplemental mold application
Phase I Site assessments (document and site evalutaion) / real estate / financial
Project Management
Process engineering and treatment plant design
Remedial design
Water brokering
Other (explain)

Total

VII - Subcontractors

What percentage of the time are current certifications of insurance received from subcontractors/subconsultants prior to the performance of work?

What percentage of the time does the Applicant require subcontractors' policies to name you as an additional insured?

What percentage of the time are total defense and indemnity agreements obtained from your subcontractors/subconsultants?

Are subcontractors/subconsultants required to have pollution liability insurance?

Yes No

If required by trade only, please identify trades

What are the minimum limits of liability required for your subcontractors/subconsultants

General Liability

Pollution Liability

Professional Liability

What percentage of the time are subcontractors/ subconsultants hired under written contract?

VIII - Contracting Procedures

What percentage of your projects have a signed contract prior to the commencement of services?

How do you evaluate clients before entering into a contract?

How do you evaluate contracts?

Who has the authority to sign contacts?

VIII - Claims and Circumstances

Has the Applicant ever been subject to any claim by any client or other third party ?

Yes No

If Yes, please explain

Has the Applicant, or project subsequent to the Applicant's performance of professional sevices or contracting operations, ever been subject to:

Any formal or informal disciplinary or enforcement action arising from any professional services or any contracting operations?

Yes No

Any action by any regulatory agency or any private party for any violation of any legal or any professional standard?

Yes No

If Yes, please describe

Does the Applicant have any knowledge of any claims or reasonably forseeable potential claims arising from:

Any professional services or any contracting operations ever provided by the Applicant?

Yes No

Any releases of any substance into the environment subsequent to the Applicant's involvement in the Project, from or at any project where the Applicant ever provided professional services or contracting Operations?

Yes No

If Yes, please explain

IX - Warranty

After reseasonable inquiry, the below signatory on behalf of the Applicant represents and warrants that the information submitted to the company in this application, and any supplementary information thereto, is true, complete and accurate and that no material or relevant fact has been suppressed or missstated as of the date such information is submitted to the company. The applicant agrees to advise the company of any changes to the information provided in this application including but not limited to any change in the information provided in this applicaiton including but not limited to any change in the professional services or contraction opertaions specifially described in this application, notices of any claim or of any ptential claim, or of any circumstances that may give rise to a claim unti the company binds a policy or until a company declines to bind a policy. If a policy is issued by the company, this application shall become part of the policy and shall be deemed to be attached to the policy.

Any misrepresentation, non-discolusre, concealment, suppression or misstatement or breach of warranty in this application or supplementary information thereto shall be construed against the applicant.

Completion of this application does not bind coverage.

Notice to Applicant - State Fraud Warnings
The meaning assigned to any defined term used in this Application shall be equally applicable to both the singular and the plural forms of such term, and words denoting any gender shall include all genders. Where a word or phrase is defined herein, each of its other grammatical forms shall have a corresponding meaning. The Applicant represents that the above statemens are true and correct to the best of the Applicant's knowledge and that material or relevant facts have bot been suppressed or mistaken. Completion of this form does not bind coverage. This Application shall become part of the policy, if any issued by the company and shall be deemed to be attached to the policy.

Notice to Arkansas Applicant
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in any application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Notice to Colorado Applicant
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 infor-mation 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.

Notice to Florida Applicant
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application con-taining any false, incomplete, or misleading information is guilty of a felony of the third degree.

Notice to Florida Applicant
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any falst, incomplete, or misleading information is guilty of a felony of the third degree.

Notice to Kentucky Applicant
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance con-taining 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 Louisiana Applicant
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 Maine Applicant
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Notice to Nebraska Applicant
No misrepresentation or warranty made by the insured or on his behalf in the negotiation or application of this policy or contract of insurance shall defeat or void the policy or contract or effect the company's obligation under this policy or contract unless such misrepresentation or warranty:
1) Was material;
2) Was made knowly with the intent to deceive;
3) Was relied and acted upon by the company; and;
4) Deeived the company to it injury.
The breach of a warranty or condition in any contract or policy of insurance shall not void the policy or allow the company to avoid liablity unless such breach exists at the time of the loss and contributes to the loss.

Notice to New Jersey Applicant
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Notice to New Mexico Applicant
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents falst information in an application for insurance is guilty of a crime and may be subject to civil and criminal penalties.

Notice to New York Applicant
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 exceed five thousand dollars and the stated value of the claim for each such violation.

Notice to Ohio Applicant
Any person who with intent to defraud or knowingly that he/she 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 Applicant
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Notice of Pennsylvania Applicant
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 Applicant
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fine and denial of coverage.

Notice to Utah Applicant
Any person who knowingly presents false or fraudulent underwriting information, files or auses to be filed a false or fraudulent claim for disability compensaiton or medical benefits, or submits a flase or fraudulent report of billing for health care fees or other professional services if guilty of a crime and may be subject to fines and confinement in state prison.

Notice to Virginia Applicant
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fine and denial of insurance benefits.

Notice to Washington D.C. Applicant
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 fine. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.

Notice to All Other State 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 false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime in certain jurisdictions.

IX - Applicant Information

Applicant's signature

Applicant's name

Date

Title

Insurance Representative

Address

City

State

ZIP Code

Telephone number

Fax number

Email address

Surplus Lines Agent (SLA) (for the state where the named insured is domiciled)

Address

City

State

ZIP Code

Surplus lines license number

Email address

Geologists Program - Get a Quote

Contractors and Consultants Pollution Liability Application

Comegys Insurance Corner

Contractors and Consultants
Pollution Liability Application