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1) Effective Date: From
to
2 ) Entity:
Corporation
Partnership
Individual
Other
3)Coverage
a) Liability Only
(Coverage A)
b) Liability and
Site Clean-up (Coverage A and B)
c)
Liability, Site Clean-up, and Property Coverage (Cov. A, B, and C)
4)
Deductible:
$5000
$10,000
$25,000 or
Amount of Deductible
5)
Policy Limit (Coverage A or Coverage A and B):
$1,000,000/$ 500,000
$1,000,000/$2,000,000
$1,000,000/$1,000,000
/
Coverage C:
$25,000
6)
Retroactive Date:
Policy
Inception, Or Specify Date:
To specify date of coverage provide a copy of the prior carriers
policy to verify the current retroactive date.
7) Give
the name of the insurance company, policy number, and effective dates
of your current pollution policy.
Do
you own or operate any tanks not listed in this application subject
to registration under the Natural Resources Conservation Commission
regulations?
Yes
No
Are
there or have there been any hazardous, toxic or regulated substances,
stored at any sites for which application for insurance is being made
other than Gasoline, Diesel Fuel, Motor Oil or Kerosene? If so, what?
Have
there been or are there any fines, penalties, or legal actions currently
pending against the applicant, including state, federal, or any other
compliance order on any pollution incident?
Yes
No
At
the time of application is the applicant aware of any circumstances
which could give rise to pollution incident with regard to any sites
for which application for insurance is being made?
Yes
No
At
the time of the application, are all of the applicant's tanks listed
in this application in compliance with effective regulations set forth
by the United States Environmental Protection Agency and any state
agency with responsibility for protection of its environment or authority
to implement the regulations for protecting its environment?
Yes
No
Have
you had insurance for third-party pollution liability declined, canceled
or non-renewed?
Yes
No
The
applicant declares to the best of his/her knowledge, the statements
set forth are true. 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
by withholding information concerning any material fact thereto, commits
a fraudulent insurance act, which is a crime. Agreeing to this does
not bind the applicant or the insurance company to complete the insurance,
but is agreed this form shall be the basis of the contract should
a policy be issued. Should a policy be issued, an enforcement of this
application shall be in the same venue as enforcement of the contract
provisions. The company is authorized to make any investigation and
inquiry in connection with this application it deems necessary.
If
the applicant becomes aware of a pollution incident at any site for
which application for insurance is being made between the date of
the application and issuance of the policy, the applicant will notify
the Company immediately of the event.
I
agree
I disagree
Type your name:
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