ACE Westchester Premises Pollution Application



PREMISES POLLUTION LIABILITY COVERAGE APPLICATION – CLAIMS MADEAnswer ALL questions completely, leaving no blanks. If any questions, or part thereof, do not apply, print “N/A”.PLEASE SUBMIT THE FOLLOWING INFORMATION IN ADDITION TO THIS APPLICATION:Copies of any site specific environmental reports completed during the past 5 years for the covered location(s)Audited financial statement and balance sheet from the past two (2) yearsFive years of currently valued loss runs for all lines of coverageAPPLICANT INFORMATIONNAME OF APPLICANT FORMTEXT ?????DATE FORMTEXT ? FORMTEXT ?????MAILING ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????ZIP CODE FORMTEXT ?????WEBSITE FORMTEXT ?????PRINCIPAL ENVIRONMENTAL CONTACT FORMTEXT ?????TITLE FORMTEXT ?????TELEPHONE FORMTEXT ?????FAX FORMTEXT ?????EMAIL FORMTEXT ?????DATE FIRM WAS ESTABLISHED FORMTEXT ?????PARENT COMPANY FORMTEXT ?????Company is: FORMCHECKBOX Corporation FORMCHECKBOX Partnership FORMCHECKBOX Joint Venture FORMCHECKBOX LLC/LLP FORMCHECKBOX Other: FORMTEXT ????? REQUESTED COVERAGECOVERAGE REQUESTED FORMCHECKBOX ONSITE CLEANUP FORMCHECKBOX OFFSITE CLEAUP FORMCHECKBOX BODILY INJURY & PROPERTY DAMAGEPROPOSED EFFECTIVE DATE FORMTEXT ?????PROPOSED RETROACTIVE DATE FORMTEXT ?????PROPOSED LIMITS$ FORMTEXT ?????PROPOSED RETENTION$ FORMTEXT ?????PREVIOUS POLLUTION COVERAGECurrent CarrierEffective DatesLimitsRetentionRetroactive DatePremium FORMTEXT ????? FORMTEXT ????? to FORMTEXT ?????$ FORMTEXT ????? / $ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? to FORMTEXT ?????$ FORMTEXT ????? / $ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? to FORMTEXT ?????$ FORMTEXT ????? / $ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Has any insurance company ever denied, cancelled, or non-renewed pollution liability coverage? FORMCHECKBOX YES FORMCHECKBOX NO If “Yes”, please explain: FORMTEXT ?????COVERED LOCATION INFORMATIONPLEASE COMPLETE FOR EACH COVERED LOCATION. COPY AS NECESSARY.COVERED LOCATION INFORMATIONFACILITY NAME FORMTEXT ?????STREET ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????ZIP CODE FORMTEXT ?????SIC CODE: FORMTEXT ?????YEAR STARTED: FORMTEXT ?????ACREAGE: FORMTEXT ?????DESCRIBE CURRENT OPERATIONS AND IF ANY PRODUCTS ARE MANUFACTURED: FORMTEXT ?????DESCRIBE KNOWN HISTORICAL OPERATIONS AT THE LOCATION: FORMTEXT ?????FOR THIS LOCATION, PLEASE DESCRIBE ADJACENT PROPERTIES:NORTH FORMTEXT ?????SOUTH FORMTEXT ?????EAST FORMTEXT ?????WEST FORMTEXT ?????DISTANCE TO THE CLOSEST RESIDENTIAL AREA: FORMTEXT ?????DISTANCE TO NEAREST BODY OF WATER: FORMTEXT ?????TYPE OF WATER BODY (pond, river, stream, etc): FORMTEXT ?????NUMBER OF GROUNDWATER WELLS: FORMTEXT ?????TYPE OF WELL (drinking or monitoring): FORMTEXT ?????IS PUBLIC WATER & SEWER PROVIDED AT THIS LOCATION? FORMCHECKBOX YES FORMCHECKBOX NO IS THE LOCATION WITHIN A FLOOD PLAIN FORMCHECKBOX YES FORMCHECKBOX NOARE THERE ANY PLANS FOR FUTURE DEVELOPMENT OF THIS LOCATION? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, PLEASE DESCRIBE. FORMTEXT ?????SHIPMENT INFORMATIONFOR THIS LOCATION, PLEASE DESCRIBE THIRD PARTY SHIPMENT PROCEDURES:TYPES OF PRODUCTS SHIPPED: FORMTEXT ?????AMOUNT OF PRODUCTS SHIPPED PER WEEK: FORMTEXT ?????METHOD OF SHIPMENT (RAILROAD, AUTO, TRUCK, BOAT, etc): FORMTEXT ?????ARE PRODUCTS SHIPPED BY PROPERLY LICENSED CARRERS? FORMCHECKBOX YES FORMCHECKBOX NO ADDITIONAL INFORMATIONFOR THIS LOCATION, PLEASE IDENTIFY: HAZARDOUS MATERIALS/CHEMICALS USED, TREATED, OR STORED? FORMCHECKBOX YES FORMCHECKBOX NO (IF YES, COMPLETE ADDENDUM A)ANY TREATMENT FACILITIES? FORMCHECKBOX YES FORMCHECKBOX NO (IF YES, COMPLETE ADDENDUM B)LANDFILL, TRANSFER STATION, OR RECYCLING FACILITY? FORMCHECKBOX YES FORMCHECKBOX NO (IF YES, COMPLETE ADDENDUM C)UNDERGROUND OR ABOVE GROUND STORAGE TANKS? FORMCHECKBOX YES FORMCHECKBOX NO (IF YES, COMPLETE ADDENDUM D)If you answer yes to any of the above, a completed addendum will need to be provided.ENVIRONMENTAL INFORMATIONHAVE ANY ENVIRONMENTAL STUDIES, REPORTS, OR AUDITS (SUCH AS AN ENVIRONMENTAL SITE ASSESSMENT) EVER BEEN PREPARED FOR THIS LOCATION? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, PLEASE PROVIDE COPIES WITH THIS APPLICATION.DOES THE LOCATION HAVE ANY RELEVANT ENVIRONMENTAL PERMITS (RCRA, UST, NPDES, etc.)? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, PLEASE PROVIDE COPIES WITH THIS PLIANCE HISTORYARE YOU AWARE OF ANY NOTICES OF VIOLATION, FINES, PENALITIES, COMPLAINTS, OR RECEIVED ANY CLAIMS OR SUITS RELATING TO ANY POLLUTION CONDITIONS? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, PLEASE EXPLAIN: FORMTEXT ?????ARE YOU AWARE OF ANY PAST OR PRESENT POLLUTION CONDITIONS, OR ANY CIRCUMSTANCES WHICH MAY REASONABLY BE EXPECTED TO GIVE RISE TO A CLAIM? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, PLEASE EXPLAIN: FORMTEXT ?????ARE YOU AWARE IF ANY OF THE COVERED LOCATION(S) ARE IN NON-COMPLIANCE OF ANY LOCAL, STATE, OR FEDERAL ENVIRONMENTAL REGULATIONS, STANDARDS, OR STATUES? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, PLEASE EXPLAIN FORMTEXT ?????*IT IS UNDERSTOOD AND AGREED THAT IF ANY SUCH CLAIMS EXIST, OR ANY SUCH FACTS OR CIRCUMSTANCES EXIST WHICH COULD GIVE RISE TO A CLAIM, THEN THOSE CLAIMS AND ANY OTHER CLAIMS ARISING FROM SUCH FACTS OR CIRCUMSTANCES ARE EXCLUDED FROM THE PROPOSED INSURANCE UNLESS OTHERWISE AFFIRMATIVELY STATED IN THE POLICY.BY SIGNING THIS APPLICATION, THE APPLICANT WARRANTS TO THE COMPANY THAT ALL STATEMENTS MADE IN THIS APPLICATION INCLUDING ATTACHMENTS, ABOUT THE APPLICANT AND ITS OPERATIONS ARE TRUE AND COMPLETE, AND THAT NO MATERIAL FACTS HAVE BEEN MISSTATED IN THIS APPLICATION OR CONCEALED. COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. THE APPLICANT’S ACCEPTANCE OF THE COMPANY’S QUOTATION IS REQUIRED BEFORE THE APPLICANT MAY BE BOUND AND A POLICY ISSUED.Any person who knowingly and with intent to defraud any Insurance company or ANother person, files an application for insurance or statement of claim containing any materially false information, or conceals Information for the purpose of misleading, commits a fraudulent insurance act. such an act is a crime and subjects such person to criminal and civil penalties.Signature of Authorized Applicant FORMTEXT ?????Signature of Broker/Agent FORMTEXT ?????Print Name FORMTEXT ?????Print Name FORMTEXT ?????Title FORMTEXT ?????Agency Name FORMTEXT ?????DateDateACE Westchester Specialty Group - Environmental Division500 Colonial Center Parkway, Suite 200 Roswell, GA 30076Phone: 1-800-982-9826 Fax: 678-795-4569 ?Email: wsgatl.environmental@ace-ADDENDUM A – CHEMICAL USE, STORAGE, TRANSPORT AND TREATMENTPLEASE COMPLETE FOR EACH COVERED LOCATION. COPY AS NECESSARYCOVERED LOCATION INFORMATIONNAME, STREET ADDRESS, CITY, STATE, ZIP CODE: FORMTEXT ?????FACILITY EPA ID #: FORMTEXT ?????STATE ID #: FORMTEXT ?????DESCRIBE CURRENT PERMITS FOR THIS LOCATION: FORMTEXT ?????DESCRIBE HAZARDOUS MATERIAL/CHEMICAL USE FOR THIS LOCATION:CHEMICAL NAMEAMOUNT ONSITEAMOUNT USED IN ONE YEARMETHOD OF STORAGE (drums, etc.) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DESCRIBE HAZARDOUS MATERIAL/CHEMICAL TREATMENT AND DISPOSAL PROCEDURES FOR THIS LOCATION:WASTE TYPEQUANITYTREATMENT/DISPOSAL METHOD FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ADDENDUM B – TREATMENT FACILITIESPLEASE COMPLETE FOR EACH COVERED LOCATION. COPY AS NECESSARYCOVERED LOCATION INFORMATIONNAME, STREET ADDRESS, CITY, STATE, ZIP CODE: FORMTEXT ?????FACILITY EPA ID #: FORMTEXT ?????STATE ID #: FORMTEXT ?????IS THE FACILITY PERMITTED? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, BY WHOM? FORMTEXT ?????FACILITY BACKGROUNDTYPE OF TREATMENT FACILITY (CHECK BOX) FORMCHECKBOX PROCESS WATER FORMCHECKBOX WASTEWATER FORMCHECKBOX DRINKING WATER FORMCHECKBOX HAZARDOUS WASTE FORMCHECKBOX OTHER: FORMTEXT ?????WHEN WAS THE FACILITY BUILT? FORMTEXT ?????WHEN WAS THE FACILITY PERMITTED? FORMTEXT ?????MAXIMUM PERMITTED AMOUNT TREATED: FORMTEXT ?????AVERAGE DAILY AMOUNT TREATED: FORMTEXT ?????PLEASE DESCRIBE TREATMENT METHODS: FORMTEXT ?????IS ANY TREATED MATERIAL OR BY-PRODUCT SOLD OR GIVEN AWAY? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, PLEASE EXPLAIN. FORMTEXT ?????WHERE IS EFFLUENT DISCHARGED: FORMTEXT ?????HOW IS ACCESS TO THE FACILITY CONTROLLED? FORMTEXT ?????DOES THE FACILITY TREAT ANY RADICACTIVE WASTE? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, PLEASE EXPLAIN. FORMTEXT ?????EMERGENCY RESPONSE PROCEDURESDOES THE FACILITY HAVE A WRITTEN EMERGENCY RESPONSE PLAN? FORMCHECKBOX YES FORMCHECKBOX NO (IF YES, PLEASE PROVIDE A COPY WITH THIS APPLICATION)ARE EMPLOYEES TRAINED ON EMERGENCY RESPONSE PROCEDURES? FORMCHECKBOX YES FORMCHECKBOX NO HOW OFTEN? FORMTEXT ?????ADDENDUM C – RECYCLING FACILITIES, TRANSFER STATIONS, OR LANDFILLSPLEASE COMPLETE FOR EACH COVERED LOCATION. COPY AS NECESSARY.COVERED LOCATION INFORMATIONNAME, STREET ADDRESS, CITY, STATE, ZIP CODE: FORMTEXT ?????FACILITY EPA ID #: FORMTEXT ?????STATE ID #: FORMTEXT ?????IS THE FACILITY PERMITTED? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, BY WHOM: FORMTEXT ?????FACILITY BACKGROUNDTYPE OF TREATMENT FACILITY (CHECK BOX) FORMCHECKBOX MUNICIPAL LANDFILL FORMCHECKBOX CONSTRUCTION & DEBRIS LANDFILL FORMCHECKBOX HAZARDOUS WASTE LANDFILL FORMCHECKBOX TRANSFER STATION FORMCHECKBOX RECYCLING FACILITY FORMCHECKBOX OTHER: FORMTEXT ?????WHEN WAS THE FACILITY BUILT? FORMTEXT ?????WHEN WAS THE FACILITY PERMITTED? FORMTEXT ?????MAXIMUM PERMITTED DAILY TONNAGE AMOUNT ACCEPTED: FORMTEXT ?????AVERAGE DAILY TONNAGE AMOUNT ACCEPTED: FORMTEXT ?????TOTAL ACRES: FORMTEXT ?????DISPOSAL ACRES: FORMTEXT ?????BUFFER ACRES: FORMTEXT ?????BUFFER USE: FORMTEXT ?????PLEASE DESCRIBE MATERIALS ACCEPTED BY THIS FACILITY: FORMTEXT ?????HOW IS ACCESS TO THE FACILITY CONTROLLED? FORMTEXT ?????DOES THE FACILITY CURRENT MONITOR THE GROUNDWATER? FORMCHECKBOX YES FORMCHECKBOX NO IF YES, PLEASE PROVIDE MOST RECENT GROUNDWATER MONITORING REPORTS WITH THIS APPLICATION. CELL INFORMATIONID No. FORMTEXT ?????ID No. FORMTEXT ?????ID No. FORMTEXT ?????ID No. FORMTEXT ?????ACTIVE OR CLOSED FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DATE FIRST USED FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ESTIMATED CLOSURE DATE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LINER TYPE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LINER THICKNESS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LEACHATE COLLECTION SYSTEM FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????METHANE COLLECTION SYSTEM FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????GROUNDWATER MONITORING SYSTEM FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ADDENDUM D – STORAGE TANKSPLEASE COMPLETE FOR EACH COVERED LOCATION. COPY AS NECESSARY.COVERED LOCATION INFORMATIONNAME, STREET ADDRESS, CITY, STATE, ZIP CODE: FORMTEXT ?????FACILITY EPA ID #: FORMTEXT ?????STATE ID #: FORMTEXT ?????NUMBER OF ABOVEGROUND STORAGE TANKS: FORMTEXT ?????NUMBER OF UNDERGROUND STORAGE TANKS: FORMTEXT ?????STORAGE TANK SCHEDULEID No. FORMTEXT ?????ID No. FORMTEXT ?????ID No. FORMTEXT ?????ID No. FORMTEXT ?????ID No. FORMTEXT ?????AST OR UST FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????AGE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CAPACITY (gallons) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PRODUCT CODE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CONSTRUCTION CODE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PROTECTION CODE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????LEAK DETECTION CODE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Secondary Containment CODE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????MOST RECENT TANK TESTING DATE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DID IT PASS OR FAIL? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????HAS THIS TANK BEEN UPGRADED TO THE 1998 STANDARDS? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ASSOCIATED PIPINGLENGTH OF PIPING (feet) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????AGE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????% OF PIPING UNDERGROUND FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CONSTRUCTION CODE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PROTECTION CODE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DISPENSER CODE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????OIL/WATER SEPARATOR IN USE? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CODESPRODUCT CODECONSTRUCTION CODEPROTECTION CODED – DieselDWS – Double Wall SteelCP – Cathodic ProtectionG – GasolineDWF – Double Wall FiberglassEC – Epoxy CoatedA – AviationSTIP – STIP-3 ConstructionV – Tank VaultU – Used OilSWS – Single Wall SteelPL – Pit LinerO – Organic ChemicalsSWF – Single Wall FiberglassN – NoneI – Inorganic ChemicalsLS – Lined SteelP – Painted TankUNK - UnknownUNK - UnknownLEAK DETECTION CODESECONDARY CONTAINMENT CODEDISPENSING CODEE – Electronic MonitoringPC- Poured ConcreteS – SuctionDS – Dip StickCB – Concrete BlockP – PressureMW – Monitoring WellE – EarthPT – Pressure TestL – Lined SI – Statistical InventoryN – NoneN - NoneUNK - UnknownUNK - Unknown ................
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