Insurance Pollution Policy Application

INSURANCE POLLUTION POLICY APPLICATION

Applicant / Insured Information

Individual Corporation LLC Partnership Other:

Policy Details Requested

Policy Type: Occurrence Claims-Made

Coverage Options

Select coverage sections being requested (select all that apply):

On-site Pollution Liability (including sudden & accidental)

Cleanup, Remediation and Removal Costs

Third-Party Bodily Injury & Property Damage

Transportation Pollution Liability

Contractors Pollution Liability

Legal Defense Costs (Defense within limits)

Emergency Response & First Responder Costs

Exclusions and Limitations

The policy applied for will contain standard exclusions including, but not limited to: intentional pollution acts, pollution resulting from war or nuclear hazards, fines and penalties imposed by governmental authorities (unless otherwise insurable by law), liabilities covered under workers' compensation or employers' liability, and liabilities resulting from prior known and reported conditions except as specifically endorsed. Applicant should identify any non-standard exclusion requested or required below.

Prior Insurance & Loss History

Have you ever purchased Pollution Liability coverage before?   Yes No

In the past five years, has applicant had any pollution incidents, losses or claims (including near-miss releases) arising from operations?   Yes No

Operations, Materials and Controls

Do you store, handle or transport regulated hazardous substances on-site?   Yes No

Secondary containment Formal spill response plan Employee hazardous materials training Permits and regulatory compliance documentation maintained

Beneficiary / Loss Payee

Beneficiary or Loss Payee (if applicable):

Relationship to Insured:    Percentage:

Attachments / Supporting Documentation

The following documents are recommended to support underwriting. Indicate those attached to this application:

Site map / facility diagram Environmental audit or Phase I Spill response plan

Declarations, Certifications and Consent

I hereby warrant that the statements made in this application are true, complete and correct to the best of my knowledge and belief. I acknowledge that this application, including any attachments, shall form the basis of any policy issued and that material misrepresentation, omission or fraudulent statements may render coverage void or permit the insurer to rescind the policy in accordance with applicable law.

I authorize the insurer, its representatives and any provider of environmental consultant or loss history information to obtain and exchange loss experience, claims, underwriting and financial information relevant to this application. I consent to the insurer performing inspections, audits and inquiries as required for underwriting and claim handling purposes.

The applicant understands that coverage is not in force until a policy is issued and the required premium(s) are accepted by the insurer. Quoted terms and rates are subject to change on review of completed application and supporting documentation.

Fraud Warning: 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 may be subject to criminal and civil penalties.

I certify that the information provided is true, accurate and complete.

Signature

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