APPLICATION
IT IS IMPORTANT THAT YOU CAREFULLY READ ALL OF THE PROVISIONS OF ANY POLICY ISSUED AS A RESULT OF THIS APPLICATION. SOME COVERAGE MAY BE ON A CLAIMS-MADE AND REPORTED BASIS.
DEFENSE EXPENSES ARE INCLUDED WITHIN THE LIMITS OF COVERAGE, AND SUCH LIMITS MAY BE COMPLETELY EXHAUSTED BY THE PAYMENT OF DEFENSE EXPENSES. THE COMPANY WILL NOT BE LIABLE FOR DEFENSE EXPENSES OR THE AMOUNT OF ANY JUDGMENT OR SETTLEMENT AFTER EXHAUSTION OF THE LIMITS OF COVERAGE.
Answer each question on behalf of all entities seeking insurance coverage, unless specifically requested otherwise. “You” or “your” means any entity (corporation, organization, or other entity, including subsidiaries) that is requesting insurance coverage. An additional information section is provided at the end of the document for any information that exceeds the space provided.
GENERAL INFORMATION
Proposed First Named Insured & Other Named Insured(s): / EPA ID Number if applicable: / Today's Date:REQUIRED ATTACHMENTS
Include the following with the submission:
· Statement of qualifications package, include resumes of key personnel
· Currently valued pollution liability loss runs for the past 5 years
· Commercial General Liability (CGL) loss runs for the past five years
· Copy of expiring Contractors Pollution Liability (CPL) policy, including endorsements, if applicable
· Representative executed contract (s) utilized with client and subcontractors
· Environmental, Health and Safety Manual, including Emergency Response Plan, or Standard Operating Procedure Manual. If none is available, submit any documents pertaining to such procedures.
· Audited financial statements/Annual Reports for the applicant for past two years
· Copy of current, completed and signed ACORD 125 (Commercial Insurance Application - Applicant Information Section) and ACORD 126 (Commercial General Liability Section)
COVERAGE REQUESTED
1. Complete all that apply:
Claims-Made Coverage Occurrence-Type CoverageLimits (Each/Aggregate)
Option 1 / Limits (Each/Aggregate) - Option 2 / Deductible
Option 1 / Deductible
Option 2
Option 1 / Option 2 / Option 1 / Option 2
Proposed Effective Date / Retroactive Date / Desired Policy Period / New or Renewal
CURRENT/PAST CONTRACTORS POLLUTION LIABILITY COVERAGE
2. Complete the following:
Insurance Carrier / Limits of Liability(Each/Aggregate) / Coverage Trigger (Claims-Made or Occurrence) / Deductible/SIR / Policy Period / Premium
GEOGRAPHIC AREA OF OPERATIONS
3. Complete the following:
Domestic / % Total Revenues / Key States:Canada / % Total Revenues / Key Provinces:
Foreign / % Total Revenues / Key Countries:
BREAK DOWN OF REVENUES
4. Break down the revenues shown above by the services or operations shown below.
Contracting Services or Operations
/Estimated Gross Revenue
/% Subcontracted
/Above Ground Storage Tanks Installation/Removal / $ / %
Air Emissions Control Equipment Installation / $ / %
Asbestos Abatement / $ / %
Barrier/Liner Construction / $ / %
Carpentry / $ / %
Demolition - Explosive / $ / %
Demolition - Interior / $ / %
Demolition - Non-Explosive / $ / %
Dismantling / $ / %
Dredging / $ / %
Electrical / $ / %
Emergency Response / $ / %
Environmental Remediation / $ / %
Environmental - Other / $ / %
Excavation Grading/Site Prep / $ / %
Fire/Water Damage Restoration / $ / %
Groundwater Sampling / $ / %
Hazardous Material/Waste Cleanup / $ / %
Heavy Highway/Bridge / $ / %
HVAC / $ / %
Industrial Cleaning / $ / %
Insulation / $ / %
Lead Abatement / $ / %
Maintenance/Janitorial / $ / %
Marine / $ / %
Masonry/Concrete / $ / %
Mechanical / $ / %
Mold Remediation / $ / %
Oil and Gas Services / $ / %
Painting / $ / %
PCB Handling/Retrofitting / $ / %
Pesticide/Herbicide Application / $ / %
Pile Driving / $ / %
Pipeline Construction/Cleaning / $ / %
Plant Maintenance / $ / %
Plumbing / $ / %
Rigging/Stevedoring / $ / %
Roofing / $ / %
Sampling (Soil) / $ / %
Soil Excavation - Other than Petroleum / $ / %
Soil Excavation - Petroleum / $ / %
Soil Remediation / $ / %
Steel Erection / $ / %
Street and Road Construction / $ / %
Tank Cleaning / $ / %
Tunnel / $ / %
Underground Storage Tank Installation / $ / %
Underground Storage Tank Removal / $ / %
Underground Storage Tank Testing / $ / %
Waste Disposal / $ / %
Water Proofing / $ / %
Other (explain): / $ / %
TOTAL / $ / 100%
ALLOCATION OF GROSS REVENUES INFORMATION
5. Give the percentage of gross revenue of work held under contract or subcontracts, or as duties to fulfill scope of work for which you hold direct or supervisory responsibility:
a. Acts as a general contractor / %b. Acts as an at risk construction manager / %
c. Acts as an agency construction manager / %
d. Acts as a subcontractor / %
e. Design or consulting services (for work other than environmental/pollution remediation) / %
f. Design or consulting services for environmental/pollution remediation / %
STAFF INFORMATION
6. Complete the following:
Total # Employed by You /# of Principals
/ # of Environmental Engineers / # of Remediation Personal / # of Project Managers/Project SuperintendentsCLIENTS/PROJECTS/SERVICES DATA INFORMATION
7. Is your company or any subsidiary, predecessor, or other organization related to your company engaged
in the manufacture, sale or distribution of any product or process or any patented production process? Yes No
8. Project Information: List the percentage of your organization’s receipts estimated for the next 12 months from the following project types.
Airports / % / Mass Transit / % / Schools/Colleges / %Bridges / % / Military Facilities / % / Shopping Center/Retail / %
Churches / % / Mines / % / Site Development / %
Dams / % / Nuclear / % / Storm Water Systems / %
Food Processing / % / Office Buildings / % / Tunnels / %
Harbors/Piers/Ports / % / Parking Structures / % / Utilities / %
Hospitals / % / Petro/Chemical / % / Warehouses / %
Hotels/Motels / % / Potable Water Systems / % / Wastewater Systems / %
Jail/Justice / % / Power Plant / % / Waste Treatment Plants / %
Landfills / % / Recreational/Sports / % / Other (Specify) / %
Libraries / % / Residential* / % / Other (Specify) / %
Manufacturing/Industrial / % / Roads/Highways / % / Other (Specify) / %
TOTAL (Combined three columns’ total must equal 100%) / 100%
*Residential includes: Single family homes, multi-family homes, residential apartments or condominiums and assisted living facilities.
9. Provide the following information on your three largest current projects:
Project 1 / Project 2 / Project 3Project Name
Location
Owner/Client
Project Type
Services Performed
Total Environmental/Pollution Revenue
Estimated Construction Value
10. What percentage of your revenue is derived from repeat clients? / %
11. What percentage of your revenue is derived from your largest client? / %
12. Do you have a financial/equity interest in any projects? Yes No
13. Do you conduct any work for or related to the oil and gas industry? Yes No
If yes, explain fully:14. Do you conduct any work related to LEED Standards or other “Green building” construction? Yes No
15. What percentage of your business is attributable to federal government contracts? / %16. What percentage of your business is attributable to state government contracts? / %
ENVIRONMENTAL/POLLUTION SERVICES INFORMATION
17. Do you bid projects that are environmental/pollution abatement or involving environmental/pollution
clean up? Yes No
18. Have you ever been involved in any projects which were located on a brownfield site? Yes No
If yes,
a. Did you perform direct remediation? Yes No
b. Were you responsible for hiring subcontractors to do remediation? Yes No
If yes, explain fully:19. Do you provide any environmental remediation not listed above:
a. Directly Yes No
b. Through hired subcontractors Yes No
If yes to a. or b., explain fully:20. Do you currently, or have you ever owned, leased, operated or maintained any hazardous waste
treatment, storage or disposal facility or any other waste facility of any kind? Yes No
21. Are you ever responsible for removing or transporting waste from job sites:
a. Directly? Yes No
b. Through hired subcontractors? Yes No
22. Are you ever responsible for selecting and contracting with a waste facility for disposal of waste? Yes No
23. List any materials, chemicals, solvents, etc. transported, stored or used at your job sites (include asphalt plants, concrete plants, gasoline, diesel fuel, approximate quantities and method of storage). Describe tank capacity for fuel and other materials, age of tanks, surrounding areas, spill prevention and control methods used at your staging areas and job sites:
SUBCONTRACTING CONTROLS INFORMATION
24. Do you secure certificates of insurance from your environmental/pollution remediation subcontractors
evidencing their pollution liability coverage? Yes No
26. Do you maintain current in-force certificates from your environmental remediation subcontractors’
pollution liability insurance carriers for work that has been completed? Yes No
27. Do you require notice of cancellation, nonrenewal or material change of your environmental remediation subcontractors’ pollution-liability insurance for current work or work that has been completed? Yes No
28. Do your subcontracts require your environmental remediation subcontractors to indemnify you for loss
resulting from their acts, errors or omissions? Yes No
29. Do your subcontracts require that you be an additional insured on your environmental remediation
subcontractors’ pollution liability policies? Yes No
30. Type of subcontract agreement used:
a. U.S.: AIA or AGC standard forms of agreement / %b. Canada: ACEC, CCAC or CCDC standard forms of agreement / %
c. International: FIDIC standard forms of agreement / %
d. Other (specify): / %
31. How are client or subcontract agreements reviewed and negotiated? Check all that apply.
Attorney - Outside Insurance Broker or Agent Reviews
Attorney - In-House Other
Staff: / Name:Position within your organization responsible for contracts:
RISK CONTROL INFORMATION
32. Do you have a dedicated risk manager or safety officer? Yes No
33. Do you utilize written, in-house quality control procedures? Yes No
34. / Who is responsible for educating other staff members and updating such procedures?35. How often are those procedures updated?
36. Do you utilize written, in-house environmental, health and safety procedures? Yes No
If yes, check which of the following training your employees have undergone.
Asbestos Excavating, Trenching Lead Mold Remediation
Respiratory Protection Confined Space Fall Protection
List the duration and types and certification held, if applicable:37. Are formal change order provisions utilized? Yes No
If yes, provide a description of process or procedures:38. Do you conduct pre-site evaluations to determine areas of potential risk? Yes No
If yes, how and to whom are these communicated?39. Do you have and follow updated controls and written standardized protocols with respect to:
a. Handling transport of hazardous materials? Yes No
b. Use of mobile fuel tanks? Yes No
c. Location of underground utilities? Yes No
d. Disposal of waste fuels, solvents and other materials? Yes No
e. Emergency response? Yes No
f. Spill Prevention, Control and Countermeasure (SPCC) Plans? Yes No
g. Procedures for when pollution or contaminants of any kind are discovered on site? Yes No
40. If applicable, are any coverage limits purchased under your current or past Contractors Pollution
Liability coverage that are subject to the requested retroactive date less than the coverage limits
being applied for? Yes No
LOSS HISTORY INFORMATION
41. Have you ever been declined for contractors pollution liability insurance, or had such coverage
cancelled or non-renewed? (Missouri applicants – do not answer this question.) Yes No
42. Do you have any knowledge of any environmental/pollution-related claims or of any circumstances
(including but not limited to releases into air, surface water, groundwater or land) that reasonably could
give rise to potential environmental/pollution-related claims? Yes No
43. Have you or any predecessor organization, or an individual holding a management or supervisory
position with you or any predecessor organization, been cited during the last seven years or prosecuted
for contravention or violation of any standard or law related to the release of any substance into any
sewer, surface water, groundwater or air, or onto any land? Yes No
CLAIM REPORTING INFORMATION
44. / What are your internal claim reporting and investigating procedures for pollution incidents?OPTIONAL COVERAGE EXTENSIONS
45. Is coverage sought for any of the following? If so, check those that apply and include the respective supplemental application:
Fungi/Bacteria Low Level Radioactive Waste Non-Owned Disposal Sites
Auto Transportation Asbestos - Inadvertent Disturbance (Claims-Made Only)
For information about how St. Paul Surplus Lines compensates independent agents, brokers, and program managers, please visit this website:
p://www.travelers.com/w3c/legal/Producer_Compensation_Disclosure.html
If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at St. Paul Surplus Lines Insurance Company, c/o Law Department, 385 Washington St., St. Paul, MN 55102.
This application, including any material submitted in conjunction with the application or any renewal, does not amend the provisions or coverages of any insurance policy or bond issued by Travelers. It is not a representation that coverage does or does not exist for any particular claim or loss under any such policy or bond. Coverage depends on the facts and circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law. Availability of coverage referenced in this document can depend on underwriting qualifications and state regulations.