Insurance Environmental Application

INSURANCE ENVIRONMENTAL APPLICATION

Applicant / Insured Information

Date of Birth / Formation Date:

Policy Details Requested

Locations / Operations Exposed

Primary Activity at Site:

Coverage Options (check all that apply)

Third-Party Bodily Injury & Property Damage

On- and Off-site Cleanup/Remediation Costs

Defense and Legal Costs

Business Interruption and Contingent Income Loss

Transportation Pollution Liability (transit/hauling)

Contractors' Pollution Liability (for contracted work)

Operations and Exposures — Select and Describe

Underground Storage Tanks (UST)

Aboveground Storage Tanks (AST)

On-site Hazardous Waste Storage/Accumulation

Waste Treatment or Recycling

Manufacturing or Chemical Processing

Active or Planned Site Remediation

Prior Claims, Losses, and Regulatory Actions

Have there been any prior environmental claims, losses, notices of violation, or regulatory enforcement actions? Yes No

Site Investigations and Attachments

Attachments included with this application (check all that apply):

Phase I Environmental Site Assessment

Phase II / Soil & Groundwater Reports

Monitoring / Sampling Data

Environmental Permits / Compliance Records

Prior Environmental Insurance Policies

Exclusions and Acknowledgements

Applicant acknowledges that typical policy exclusions may apply, including but not limited to: intentional acts, known but undisclosed contamination, war and nuclear hazards, asbestos and lead where excluded by endorsement, and contractual liability beyond policy terms. Applicant understands that coverage, limits, sublimits and exclusions will be determined by the insurer based upon underwriting review of submitted materials.

Applicant acknowledges and authorizes the insurer and its representatives to inspect the premises, access environmental records, and obtain loss history and regulatory files necessary to underwrite this application.

Applicant acknowledges that failure to disclose material facts or submission of false or misleading information may result in denial of coverage or rescission of any issued policy.

Beneficiary / Loss Payee

Authorization and Certification

I certify that the statements contained in this application and any attachments are true, complete and accurate to the best of my knowledge. I understand that this application becomes the basis of any policy issued and that misrepresentation, omission or concealment of material facts may result in declination, rescission or denial of coverage. I authorize release of information necessary to evaluate this application including loss history, regulatory records, and environmental assessments.

I further acknowledge that submission of this application does not bind the insurer to provide insurance nor bind the applicant to purchase insurance. Coverage will be effective only upon issuance of a policy and payment of required premium.

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