Insurance CPL Renewal Form

Insurance CPL Renewal Form

Insurer:    Policy Number:

1. Applicant / Insured Information

Corporation    LLC    Partnership    Individual/Proprietor

Phone:    Email:

2. Current Policy Details

Policy Type: Contractors Pollution Liability (CPL)    Professional Liability    Package/Other

Current Policy Period From:    To:

3. Coverage Options & Extensions

Select requested extensions for renewal (coverage subject to underwriting approval):

Third-Party Property Damage (sudden & accidental)
Emergency Response & Remediation Costs
Defense Costs outside limits
Coverage for Subcontractors (as named)
Contractual Liability (subject to sublimits)

4. Prior Claims / Loss History

In the past 5 years, has the insured reported any claim, incident likely to give rise to a claim, or had any policy declined, cancelled or non-renewed?    Yes    No

5. Operations, Controls and Contracting

Describe primary operations, services performed, and any site remediation activities:

Do you use subcontractors?    Yes    No

6. Exclusions, Material Changes & Acknowledgements

Standard exclusions that may apply to renewal include, but are not limited to: asbestos, mold except as specifically endorsed, war/terrorism, intentional acts, pollution arising from known pre-existing conditions not disclosed prior to the retroactive date. Insured acknowledges that coverage remains subject to the policy's full terms, conditions and exclusions.

Have there been any material changes in operations, ownership, management, or revenue since the prior policy inception?    Yes    No

7. Claim Payment Beneficiary / Claim Payee

If claim payments are to be made to an entity or third party other than the Named Insured, provide payee details below. Note: insurer reserves right to verify payee authority prior to payment.

8. Required Attachments (checklist)

The following documents must accompany this renewal application where applicable:

Loss runs for the prior 5 years
Safety / Environmental Management Program documentation
Representative contracts or hold-harmless agreements
Subcontractor schedule and certificates

9. Declaration and Authorization

The undersigned declares that the information provided in this renewal form and any attachments is true, complete and accurate to the best of their knowledge. The undersigned understands that this renewal application becomes a part of the policy file and that any material misrepresentation, omission or concealment of fact may give the insurer grounds to void coverage, rescind the policy, or deny coverage for a claim.

The undersigned authorizes the insurer and its authorized representatives to obtain and review underwriting information, loss history, claim files, and other information pertinent to the evaluation of this renewal request. The undersigned understands that coverage under any renewed policy is subject to the insurer's underwriting acceptance and to all terms, conditions, limitations and exclusions of the policy form and endorsements issued.

By signing below, the undersigned certifies that there has been no deliberate circumvention of policy provisions, and affirms that any known pollution conditions, pre-existing incidents, or circumstances that may give rise to a claim have been fully disclosed in this application or accompanying documentation.

10. Signature

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