Insurance Pollution Liability Application

INSURANCE POLLUTION LIABILITY APPLICATION

Applicant / Insured Information

Entity Type

Please indicate the legal form of the insured entity (check all that apply).

Policy Details Requested

Policy Type: Occurrence Claims-Made

Operations, Locations, and Activities

On-site storage, handling or treatment of regulated substances (check all that apply):

Prior Pollution Losses, Notices & Regulatory Actions

Have there been any pollution releases, environmental notices, fines, citations, claims or corrective actions involving the applicant or any locations to be insured in the past ten (10) years? Yes No

Requested Coverages

Select coverages requested (checking does not bind coverage; subject to underwriting and policy terms).

Exclusions and Limitations (Typical)

Standard exclusions that may apply include, but are not limited to: (a) intentional acts or willful noncompliance by the insured; (b) known contamination not disclosed on this application; (c) asbestos, lead in construction materials and naturally occurring radioactive materials unless specifically endorsed; (d) bodily injury or property damage subject to pollution statutes where coverage is barred by law; (e) fines, penalties, punitive damages where uninsurable under applicable law unless otherwise agreed in writing.

Beneficiary / Additional Insured / Loss Payee

List any mortgagees, additional insureds, loss payees or other parties with an insurable interest to be named on the policy. Attach supporting documentation if required.

Attachments and Documentation Checklist

Please attach or provide the following as applicable. Check those attached.

Representations, Warranty and Certification

The undersigned hereby declares that to the best of their knowledge the statements made in this application and in any attachments are true, complete and material to the insurer's consideration of this risk. The undersigned warrants that no person proposed for insurance has knowledge or information of any circumstance which could reasonably be expected to give rise to a claim under the proposed policy other than as disclosed in this application.

The applicant acknowledges that this application shall be the basis of any policy issued and that any policy issued may be rescinded, voided or coverage may be denied in whole or in part for material misrepresentation, omission or concealment. The applicant authorizes the insurer to make investigations and inquiries in connection with this application, including inspection of facilities and review of records and claims history.

Fraud Warning: Any person who knowingly presents false information in this application for insurance may be subject to civil and criminal penalties, including denial of coverage and referral for prosecution where applicable by law.

Acknowledgement of Application and Premium Payment

Submission of this application does not bind coverage. Coverage will be effective only upon issuance of a policy or binder and receipt of any required premium or deposit. The applicant agrees to pay premiums, taxes and fees as required under the policy. Underwriting may require modification of coverage terms, limits or conditions based on review of this application and attachments.

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