ACE Commercial Risk Services®
AUTOMOTIVE PREMISES POLLUTION LIABILITY APPLICATION – CLAIMS MADE
Answer 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:
1. Copies of any site-specific environmental reports completed during the past five (5) years for the proposed
covered location(s)
2. Five (5) years of currently valued loss runs for all lines of coverage
3. Spill Prevention Control and Countermeasure Plan (if available)
SECTION I: APPLICANT INFORMATION
NAME OF APPLICANT
DATE
MAILING ADDRESS
CITY
STATE
PRINCIPAL ENVIRONMENTAL CONTACT
TELEPHONE
ZIP CODE
TITLE
FAX
EMAIL
DATE FIRM WAS ESTABLISHED
Applicant is:
Corporation
WEBSITE
PARENT COMPANY
Partnership
Joint Venture
LLC/LLP
Other:
SECTION II: COVERAGE REQUESTED
COVERAGE REQUESTED
ONSITE CLEANUP
PROPOSED EFFECTIVE DATE
OFFSITE CLEAUP
BODILY INJURY & PROPERTY DAMAGE
PROPOSED RETROACTIVE DATE
PROPOSED LIMITS
$
PROPOSED RETENTION
$
SECTION III: PREVIOUS POLLUTION COVERAGE
Current Carrier
Effective Dates
Limits
Retention
Retroactive Date
Premium
to
$
/$
$
$
to
$
/$
$
$
to
$
/$
$
$
HAS ANY INSURANCE COMPANY EVER DENIED, CANCELLED, OR NON-RENEWED POLLUTION LIABILITY COVERAGE FOR THE
APPLICANT OR ANY OTHER NAMED INSURED TO BE COVERED PURSUANT TO THIS POLICY?
YES
NO IF “YES”, PLEASE EXPLAIN:
PLEASE COMPLETE FOR EACH PROPOSED COVERED LOCATION. COPY AS NECESSARY.
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SECTION IV: PROPOSED COVERED LOCATION INFORMATION
FACILITY NAME
STREET ADDRESS
CITY
SIC CODE:
STATE
YEAR STARTED:
ZIP CODE
ACREAGE:
DESCRIBE CURRENT OPERATIONS AND IF ANY PRODUCTS ARE MANUFACTURED AT THIS PROPOSED LOCATION:
DESCRIBE KNOWN HISTORICAL OPERATIONS AT THIS PROPOSED LOCATION:
FOR THIS PROPOSED LOCATION, PLEASE DESCRIBE ADJACENT PROPERTIES:
NORTH
SOUTH
EAST
WEST
DISTANCE TO THE CLOSEST RESIDENTIAL AREA:
DISTANCE TO NEAREST BODY OF WATER:
TYPE OF WATER BODY (pond, river, stream, etc):
NUMBER OF GROUNDWATER WELLS:
TYPE OF WELL (drinking or monitoring):
IS PUBLIC WATER & SEWER PROVIDED AT THIS PROPOSED LOCATION?
IS THIS PROPOSED LOCATION WITHIN A FLOOD PLAIN
YES
YES
NO
NO
ARE THERE ANY PLANS FOR FUTURE DEVELOPMENT OF THIS PROPOSED LOCATION?
YES
NO IF YES, PLEASE DESCRIBE.
SECTION V: SHIPMENT INFORMATION
FOR THIS PROPOSED COVERED LOCATION, PLEASE DESCRIBE THIRD PARTY SHIPMENT PROCEDURES:
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TYPES OF WASTE S AND PRODUCTS SHIPPED:
AMOUNT OF WASTES AND PRODUCTS SHIPPED PER WEEK:
METHOD OF SHIPMENT (RAILROAD, AUTO, TRUCK, BOAT, etc):
ARE WASTES AND PRODUCTS SHIPPED BY PROPERLY LICENSED
CARRERS?
YES
NO
SECTION VI: ADDITIONAL INFORMATION
FOR THIS PROPOSED COVERED LOCATION, PLEASE IDENTIFY:
UNDERGROUND OR ABOVE GROUND STORAGE TANKS?
ANY SENSITIVE ENVIRONMENTAL AREAS NEARBY?
YES
YES
NO (IF YES, COMPLETE ADDENDUM D)
NO (IF YES, PLEASE DESCRIBE )
SECTION VII: ENVIRONMENTAL INFORMATION
HAVE ANY ENVIRONMENTAL STUDIES, REPORTS, OR AUDITS (SUCH AS AN ENVIRONMENTAL SITE ASSESSMENT) EVER
BEEN PREPARED FOR THE PROPOSED COVERED LOCATION(S)?
YES
NO IF YES, PLEASE PROVIDE COPIES
WITH THIS APPLICATION.
DOES THE APPLICANT OR ANY NAMED INSURED TO BE COVERED PURSUANT TO THIS POLICY HAVE ANY
ENVIRONMENTAL PERMITS (RCRA, UST, NPDES, etc.) FOR THE PROPOSED COVERED LOCATION(S)?
YES
YES, PLEASE PROVIDE COPIES WITH THIS APPLICATION.
NO IF
DOES THE APPLICANT OR ANY NAMED INSURED TO BE COVERED PURSUANT TO THIS POLICY HAVE A SPCC PLAN
(SPILL PREVENTION, CONTROL AND COUNTERMEASURE PLAN) IN PLACE FOR THE PROPOSED COVERED
LOCATION(S)?
YES
NO IF YES, PLEASE PROVIDE COPIES WITH THIS APPLICATION.
SECTION VIII: COMPLIANCE HISTORY
IS THE APPLICANT OR ANY OTHER NAMED INSURED TO BE COVERED PURSUANT TO THIS POLICY AWARE OF ANY NOTICES OF
VIOLATION, FINES, PENALITIES, COMPLAINTS, OR HAVE THEY RECEIVED ANY CLAIMS OR SUITS RELATING TO ANY
POLLUTION CONDITIONS?
YES
NO
IF YES, PLEASE EXPLAIN:
IS THE APPLICANT OR ANY OTHER NAMED INSURED TO BE COVERED PURSUANT TO THIS POLICY AWARE OF ANY PAST OR
PRESENT POLLUTION CONDITIONS, OR ANY CIRCUMSTANCES WHICH MAY REASONABLY BE EXPECTED TO GIVE RISE
TO A CLAIM?
YES
NO
IF YES, PLEASE EXPLAIN:
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IS THE APPLICANT OR ANY OTHER NAMED INSURED TO BE COVERED PURSUANT TO THIS POLICY AWARE IF ANY OF THE
PROPOSED COVERED LOCATION(S) ARE NOT IN NON-COMPLIANCE OF ANY LOCAL, STATE, OR FEDERAL
ENVIRONMENTAL REGULATIONS, STANDARDS, OR STATUES?
YES
NO
IF YES, PLEASE EXPLAIN
*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 ITS AUTHORIZED REPRESENTIVE SIGNING THIS APPLICATION, THE APPLICANT WARRANTS TO THE COMPANY
THAT ALL STATEMENTS MADE IN THIS APPLICATION INCLUDING ATTACHMENTS, ABOUT THE APPLICANT, ANY OTHER
NAMED INSURED TO BE COVERED PURSUANT TO THE POLICY, AND THEIR 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.
Name of Applicant
Signature of Authorized Representative
Signature of Broker/Agent
Print Name
Print Name
Title
Agency Name
Date
Date
ACE Commercial Risk Services®
Royal Centre Two, 11575 Great Oaks Way, Suite 200, Alpharetta, GA 30022
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ADDENDUM D – STORAGE TANKS
PLEASE COMPLETE FOR EACH PROPOSED COVERED LOCATION. COPY AS NECESSARY.
PROPOSED COVERED LOCATION INFORMATION
NAME, STREET ADDRESS, CITY, STATE, ZIP CODE:
FACILITY EPA ID #:
STATE ID #:
NUMBER OF ABOVEGROUND STORAGE TANKS:
NUMBER OF UNDERGROUND STORAGE TANKS:
STORAGE TANK SCHEDULE
ID No.
ID No.
ID No.
ID No.
ID No.
AST OR UST
AGE
CAPACITY (gallons)
PRODUCT CODE
CONSTRUCTION CODE
PROTECTION CODE
LEAK DETECTION CODE
SECONDARY CONTAINMENT CODE
MOST RECENT TANK TESTING DATE
DID IT PASS OR FAIL?
HAS THIS TANK BEEN
UPGRADED TO THE 1998
STANDARDS?
ASSOCIATED PIPING
LENGTH OF PIPING (feet)
AGE
% OF PIPING UNDERGROUND
CONSTRUCTION CODE
PROTECTION CODE
DISPENSER CODE
OIL/WATER SEPARATOR IN USE?
CODES
PRODUCT CODE
D – Diesel
G – Gasoline
A – Aviation
U – Used Oil
O – Organic Chemicals
I – Inorganic Chemicals
CONSTRUCTION CODE
DWS – Double Wall Steel
DWF – Double Wall Fiberglass
STIP – STIP-3 Construction
SWS – Single Wall Steel
SWF – Single Wall Fiberglass
LS – Lined Steel
UNK - Unknown
PROTECTION CODE
CP – Cathodic Protection
EC – Epoxy Coated
V – Tank Vault
PL – Pit Liner
N – None
P – Painted Tank
UNK - Unknown
LEAK DETECTION CODE
E – Electronic Monitoring
DS – Dip Stick
MW – Monitoring Well
PT – Pressure Test
SI – Statistical Inventory
N - None
UNK – Unknown
SECONDARY CONTAINMENT CODE
PC- Poured Concrete
CB – Concrete Block
E – Earth
L – Lined
N – None
UNK - Unknown
DISPENSING CODE
S – Suction
P – Pressure
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