Insurance Pollution Request Form

INSURANCE POLLUTION REQUEST FORM

Applicant Information

Applicant Name:

Individual Corporation LLC Partnership Other:

Contact Phone:    Email:

Date of Birth (if individual):    Tax ID / EIN / SSN:

Insured / Policy Information

Policy Number:    Policy Type: Occurrence Claims-made Other:

Current Coverage Amount: $    Current Deductible: $

Annual Premium: $

Policy Period Start:    End:

Requested Pollution Coverage

Requested Effective Date:    Retroactive Date (if applicable):

Cleanup and remediation costs Third-party bodily injury & property damage First-party property damage Transportation and storage coverage Legal defense costs

Requested Limit Amount: $    Requested Deductible: $

Loss History and Claim Information

Have there been any pollution-related incidents, claims, notices, or regulatory actions in the past 5 years? Yes No

Most Recent Loss Date:    Total Paid to Date: $

Documentation Checklist

Please provide or indicate which documents are attached with this request:

Site photographs Environmental investigation reports Remediation cost estimates

Regulatory or enforcement notices Prior pollution policies / loss run Other documents:

Exclusions and Limitations

The undersigned acknowledges that any subsequent coverage, if issued, will be subject to policy terms, conditions, definitions and exclusions. Common pollution policy exclusions include, but are not limited to: intentional acts or willful noncompliance; gradual pollution unless specifically endorsed; punitive damages where unenforceable; costs required by statute to be borne by the insured; coverage for pollutants as defined in policy language; and any exclusion imposed by endorsement. The insurer reserves the right to apply additional exclusions, sublimits, or conditions based on underwriting review of site activities, previous losses, and available information.

Beneficiary Designation (for claim payment purposes)

Beneficiary Name:

Relationship to Applicant:    Percentage of Payment: %

Declaration and Authorization

I certify that the information contained in this Insurance Pollution Request Form and any attachments is true, complete, and accurate to the best of my knowledge. I understand that submission of this request does not bind the insurer to provide coverage, and any coverage offered will be subject to the insurer's underwriting review and policy terms, conditions, endorsements and exclusions. I authorize the insurer, its representatives and designated agents to obtain and review loss history, environmental reports, inspection findings, regulatory files, and other information necessary to evaluate this request. I agree to provide additional documentation requested by the insurer and to cooperate with reasonable requests for site access or testing, if required.

I understand that material misrepresentation, omission, or fraudulent statements in connection with this request may result in denial of coverage, rescission of any policy issued, or other remedies permitted by law and policy. I further acknowledge that estimates of cleanup or remediation cost supplied by or on behalf of the applicant are preliminary and subject to verification; the insurer shall not be liable for expenses incurred by the applicant prior to issuance of a policy and the effective date of any such policy.

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