Instructions: Please type or print clearly.
Answer ALL questions completely, leaving no blanks. If any questions, or part thereof, do not apply, print "N/A" in the space.
Provide any supporting information on a separate sheet using the Applicant's letterhead and reference the applicable question number.
Check Yes or No answers.
This form must be completed, dated and signed by an authorized representative of the Applicant.
Required Attachments:
Please provide copies of the Applicant's past two (2) years of audited financial statements and annual reports.
Summary of Environmental Site Assessments/Remediation (past, current, planned)
Notice to Applicant: THE COVERAGE APPLIED FOR IS SOLELY AS STATED IN THE POLICY AND ANY ENDORSEMENT THERETO. THE POLICY PROVIDES LIABILITY COVERAGE ON A CLAIMS-MADE AND REPORTED BASIS, WHICH COVERS ONLY CLAIMS FIRST MADE AGAINST AN INSURED AND REPORTED TO THE INSURER, IN WRITING, UDRING THE POLICY PERIOD. THE POLICY ALSO PROVIDES COVERAGE FOR REMEDIATION COSTS ON A DISCOVERED AND REPORTED BASIS, WHICH COVERS ONLY POLLUTION CONDITIONS FIRST DISCOVERED AND REPORTED TO THE INSURER, IN WRITING, DURING THE POLICY PERIOD.
Upload Details If "yes" is indicated with respect to questions above, please provide a detailed description of the claim or circumstance (indicate the alleged incident, location, date, type of injury, etc.) Also, please provide a summary of any steps that may have been taken to avoid or mitigate the possibility of similar loss occurring in the future.
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 OF CIRCUMSTANCES ARE EXCLUDED FROM THE PROPOSED INSURANCE UNLESS OTHERWISE AFFIRMATIVELY STATED IN THE POLICY.
UNDERSTOOD AND AGREED *IT IS UNDERSTOOD AND AGREED THAT IF ANY SUCH CLAIMS EXIST, OR ANY SUCH FACTS OR CIRCUMSTANCES EXIST WHICH COULD IVE 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.
