(866) 670-5948

CONTRACTORS POLLUTION LIABILITY APPLICATION
PLEASE ANSWER ALL QUESTIONS IN FULL
NOTICE:  If a policy is issued, the limit of liability available to pay judgments for settlements shall be reduced by amounts incurred for legal defense.  Further note that amounts incurred for legal defense shall be applied against the deductible or retention amount.

APPLICANT
	DATE			
ADDRESS
				
CITY
	STATE	ZIP CODE	TELEPHONE #	

Company is an:  Individual____  Partnership____  Corporation____  Joint Venture____  Other (describe) _________				
COVERAGE REQUESTED
          New Business                    Renewal	Proposed Effective Date:
			
3.     Current CGL Coverage Information
        
Carrier:	

		

Inception/Expiration Dates:	

		

Limit of Insurance:	

		

Deductible:	

		

4.     CPL - LIMITS OF LIABILITY/DEDUCTIBLE

Limits Requested:	

			

Deductible Requested:	

		

Retroactive Date Requested:	

		

	

5.                                                                               HISTORY OF COMPANY	

Date Established:	

Have there been any acquisitions, consolidations, dissolutions, and mergers?      Yes        No	

    If yes, explain:	

Does the firm have:   Subsidiaries     A parent company     Other related entities	

    If yes, explain:	

Do you share employees?     Yes       No      
    If yes, explain:	

6.            PRIOR CONTRACTORS POLLUTION LIABILITY CARRIER INFORMATION	

     CARRIER                                       RECEIPTS                           LIMITS OF LIABILITY                           DEDUCTIBLE                 PREMIUM	

	

	

7.   Any policy or coverage declined, cancelled or non-renewed during the prior three years? 
       Yes     No      If yes, explain:	

	

	

ALL APPLICANTS MUST SUBMIT THE FOLLOWING INFORMATION IN ADDITION TO THE APPLICATION:
Resumes of Key Personnel, brochures and a listing of previous projects.
Most recent annual income statement showing applicable gross sales.
Five years of currently valued CGL loss runs including pollution and professional, if applicable.
Copy of expiring policy, if any, showing retroactive dates.	

8.          Total Employees (List each person only once by primary function):

a. Principals:	

		

b. Administrators and Clerical:	

		

c. Project Supervisors / Foreman:	

		

d. Equipment Operators:	

		

e. Laborers:	

		

f. Other (specify):	

		

Please attach all key persons resumes, certifications and licenses.

	

	

9. Gross Receipts for the past 3 fiscal years:                             /                              /                                 /

                                                Dates:                                               /                             /                                  /

Note:  Gross Receipts are the total of all receipts, invoices and/or billings without any deductions of                                                any kind. Please list your estimated gross receipts including subcontracted work for the next 12 months next to the appropriate category. List services not described below under “Other” (be specific):
Contracting:	
Est. Gross Receipts:	
Contracting	
Est. Gross Receipts:	

			

Above Ground Storage Tank	
$	
Landscaping	
$	

			

Build Back / Restoration	
$	
Masonry	
$	

			

Carpentry / Framing	
$	
Mechanical Construction	
$	

			

Carpet/Upholstery Cleaning	
$	
Metal Erection	
$	

			

Concrete (Foundation)	
$	
Mold Abatement	
$	

			

Concrete (Other)	
$	
Painting (Interior)	
$	

			

Construction (Residential)	
$	
Painting (Exterior)	
$	

			

Construction (Comm./Ind)	
$	
Pile Driving	
$	

			

Debris Removal	
$	
Plumbing	
$	

			

Demolition (Interior)	
$	
Refrigeration	
$	

			

Demolition (Exterior)	
$	
Roofing (Hot Tar)	
$	

			

Dredging	
$	
Roofing (all other)	
$	

			

Drywall/Wallboard	
$	
Salvage Operations	
$	

			

Drillers (not oil & gas)	
$	
Sewer Main Construction	
$	

			

Electrical	
$	
Street Road Contracting	
$	

			

Emergency Response - Fire	
$	
Tank & Pipe Cleaning	
$	

			

Emergency Response - Sewage	
$	
UST (Installation, etc.)	
$	

			

Emergency Response - Water	
$	
UST (Removal)	
$	

			

Excavation	
$	
Waste Water	
$	

			

Flooring	
$	
Water Extraction	
$	

			

Furniture Moving	
$	
Water Main Construction	
$	

			

Grading of Land	
$	
Welding	
$	

			

HVAC	
$	
Other Contracting / Please describe:	

			

Industrial Maintenance	
$	
	
$	

			

Insulation/Fire Proofing	
$	
	
$	

			

Total Contracting Estimated Gross Sales       $____________ 	

10.      Subcontractors / Sub consultants / Independent Contractors 

             Please identify the services that you subcontract:                                          Applicable Cost 
________________________________                  $_________________________  ________________________________                  $_________________________  ________________________________                  $_________________________  ________________________________                  $_________________________  
              Does your firm collect certificates of insurance from all subcontractors?               Yes       No	

11.      Do you use a standard indemnity contract with your clients and subs?                  Yes       No  
           If no, please detail your contract procedures:___________________________________________________
           
           _______________________________________________________________________________________

           _______________________________________________________________________________________

12.      Do you install any type of liner, i.e. landfill, lagoons, etc.           Yes     No
If yes, please advise full details: _____________________________________________________________

            _______________________________________________________________________________________

13.      Do you perform any Build Back/Restoration Work that is NOT associated with mold, fire or water     damage/remediation?
             Yes     No   If yes, please advise applicable % of your total operations:                   % 	

14.      Do you perform any installation, maintenance or repair operations related to Artificial Stucco, EIFS or Exterior Installation and Finish Systems?         Yes     No

15.      Are you involved in any way in the construction of any building(s), structure(s) or addition(s)?    Yes    No  
If yes, please advise full details: _____________________________________________________________

            _______________________________________________________________________________________         	

16.      Please list all projects in which your final invoice is now more than 60 days past due.   

a______________________________________________________________________________________

b______________________________________________________________________________________

c______________________________________________________________________________________

17.      Do you conduct underground storage tank installation work?     Yes       No
           If yes, please answer the following:
                What percentage of your overall sales are associated with this operation: ____________%
                Are the installed tanks precision tightness tested before being released to owner?     Yes     No
                Do you apply any type of corrosion protection?                                                            Yes     No
                Are tanks tested and certified by a registered professional before use?                       Yes     No	

18.      Has any claim, suit or notice of incident been made against the firm or any staff member?    Yes    No
If yes, please advise or attach full details on each incident.______________________________________ __

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________	

19.	Is the applicant aware of any circumstances, which may result in any claim, suit or notice of incident against him, the firm, and his predecessors in business, any of the present or past partners or officers, or any staff member?    Yes     No          
           If yes, please advise or attach full details on each incident. ________________________________________     

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

FRAUD WARNING:  APPLICABLE TO ALL STATES
         Any person who knowingly and with intent to defraud any insurance company or other person files 
         An application for insurance or statement of claim containing any materially false information, or 
         Conceals for the purpose of misleading, information concerning any fact material thereto, commits a 
         Fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed 
         Five thousand dollars and the stated value of the claim for each such violation.

WARRANTY STATEMENT
         The undersigned authorized officer of the applicant declares that the statements set forth herein are 
         True.  The undersigned authorized officer agrees that if the information supplied on the application 
         Changes between the date of the application and the effective date of the insurance, he/she 
         (Undersigned) will immediately notify the insurer of such changes, and the insurer may withdraw or 
         modify any outstanding quotations and/or authorization or agreement to bind the insurance.  Signing 
         of this application does not bind the applicant or the insurer to complete the insurance.	

         Notice to applicants: 
a)	Any person who knowingly and with intent to defraud any insurance company or Other person files 
      an application for insurance containing any false information, or conceals for the Purpose of 
      misleading, information concerning fact material thereto, commits a fraudulent insurance Act,
      which is a crime.
b)	You agree that if the information supplied in the Application changes between the date of this 
Application and the effective date of the proposed insurance, then you will immediately notify the      Underwriters of such changes. 
          __________________________________________________
          (Signature)
          ___________________________________________________
          (Title)
          ____________________________________________________
          (Date)