COPS / E&O. AIG Europe Limited

Transcription

1 AIG Europe Limited Notice: The COPS and E&O policies provide that the limit of liability available to pay settlements or cleanup costs shall be reduced by amounts incurred for legal defense. Further note that amounts incurred for legal defense shall be applied against the deductible amount. Instructions Please complete this application. All questions applicable to each coverage applied for must be answered. If space is insufficient to complete answers, please continue on your firm's letterhead. Have this form signed and dated by an owner, partner or director/officer of your firm. See page 8 for list(s) of required submission information. Applicant s Details Name of company Address of head office line one Address line two City and postcode Attach a list of proposed Named Insureds to be covered by this policy (only those entities performing the services and/or operations as proposed will be designated as Named Insureds). Errors and Omissions Liability (E&O) Contractor s Operations and Professional Services (COPS) Check coverage(s) you are applying for Limit of liability SIR/Deductible How long has the Named Insured been in business? Proposed effective date During the past five years has the name of the applicant been changed or has any other business been purchased or have any mergers or consolidations taken place? Yes No Total professional staff of applicant Principals Supervisors / Foremen Total number of engineers and architects Total number of field personnel Hydrogeologists, Geologists, Chemists All other (describe) 1 of 8

2 Are any Joint Ventures being proposed for coverage under this policy? Yes No Are your projects bonded? Yes No Does any one project or contract represent more than 25% of annual fees? Yes No Please list the combined prior year's revenue. Contract Values From To Estimate for next 12 months Present 12 months All Operations Construction only no design Previous 12 months Profile of Operations Please complete the following for projected sales over the next 12 months. A A1 Professional Services Environmental Services Decommissioning and Demolition Remedial Investigations Feasibility Studies Remedial Design Plans and Specs Obvs/Inspect of Construction Const/Proj Management Real Estate Audits Soil Testing/Analysis Surveying Lab Testing/Analysis Asbestos/Lead/Mold Abatement Design EnvRisk Assessments/ Audits/Indoor Air Quality Asses Regulatory Consulting/Permitting 2 of 8

3 Tank Testing/Maintainance Tank System Design Waste Brokering/Rec/Arrange Health & Safety Training Total Section A1 X X A2 Non-Environmental Services Feasibility Studies Construct/Proj Management Surveying Design Other Than... Waste Water/Sewer Design Potable Water System Design Other Process/Engineering Geotechnical/Foundations/Soils HVAC/Electrical/Mechanical Eng Civil/Structural Engineering Lab Testing Construction Materials Testing Total Section A2 X X A3 Other Services Product Design (products for sale) Software Design/Programming Financial Management/Consulting Total Section A3 X X Total Section A2 X X Total Section A1 X X TOTAL SECTION A X X 3 of 8

4 B Remedial Action Contracting Operations B1 Environmental Contracting Groundwater Sampling Soil Sampling Haz Material Cleanup/soil excavation Groundwater Treatment & Recovery Waste Storage On-Site Haz Waste Treatment Mobile Incineration Barrier/Liner Contractors Emergency Haz Material Cleanup Tank Removal/Installation PCB Oil/Equip Retrofill & Removal Hydrocar./Chem. Recycling/recovery Dredging Asbestos/Lead Abatement Mold Abatement Total Section B1 X X B2 Non-Environmental Contracting Carpentry, Framing Construction Management Demolition/Dismantling Drilling Electrical Excavation/Grading General Contracting HVAC/Mechanical Industrial Cleaning (incl. sewer/septic) Insulation Logging Masonry, concrete 4 of 8

5 Marine Oil Lease Painting Pipeline Plumbing Roofing (no residential) Steel Erection Street and Road Total Section B2 X X Total Section B1 X X TOTAL SECTION B X X Section Professional Services Remedial Action Contracting Operations Grand Total Detail general radius of foreign operations (i.e. Country(ies)) where operations normally occur. Indicate percentage relative to total projected values under question 10. Does your company select or arrange for the site of disposal for hazardous or non hazardous waste on behalf of clients? Yes No Does your company own, operate or lease licensed waste treatment, storage or disposal facilities? Yes No Do you ever rent/lease equipment? Yes No Are updated certificates of insurance from subcontractors kept on file? Yes No Are these certificates required to show pollution liability insurance? Yes No If Yes, indicate percentage % 5 of 8

6 What are the minimum limits of liability you require for your subcontractors? General Liability Pollution Liability Professional Liability Do you require subcontractors policies to name you as an additional insured? Yes No If Yes, indicate percentage % Do your contracts with subcontractors contain an indemnification provision? Yes No If Yes, attach copies of all insurance requirements and indemnification clauses. If Yes, indicate percentage % Does your company enter into written contracts where you assume liability? Yes No If Yes, attach copies of all insurance requirements and indemnification clauses. If Yes, indicate percentage % Please list your current liability coverage information. Coverage Carrier Limits Expiration SIR Retrodate General Liability Contractors Pollution Liability Workers Comp Umbrella Auto Liability Errors and Omissions Do you ever make use of casual labour? Yes No Are you under a long term emergency spill cleanup contract? Yes No Please list any raw or process materials used at the jobsite (include all gasoline, kerosene, diesel fuel usage). Description of material Quantity stored on job site Method of storage (Drum / Tank) 6 of 8

7 The following two questions must be answered for all coverages. Have any claims been previously made against the applicant or reported under any other Pollution or Professional Liability policies? Yes No If Yes, state: the date when claim was made the date the incident, act or omission giving rise to the claim took place name of the claimant nature of the claim amount paid or estimated may be paid final disposition or current status It is agreed that claims made prior to the inception of the policy period are excluded from this proposed coverage, unless expressly provided otherwise in the policy or by endorsement. Is the applicant aware of any fact, circumstance or situation which could result in a claim being made against it or any other person or entity for whom coverage will be sought? Yes No Yes (Initial) Safety Are personnel trained in the use of personal protective equipment? Yes No Does your company conduct on a regular basis the following seminars? Occupational Health and Safety Yes No Management and Safety Regulations Yes No 7 of 8

8 Submission Required Information The following information is required for all policies: Brochure/statement of qualification Safety Procedure/Manual Resumes of Key Personnel including all Project Managers Hard copy of loss runs applicable to these coverages including pollution loss information. Audited financial statements (last 2 years) and current interim financial (may be unaudited) The following information is required for CPL coverage. Spill or Emergency Contingency Plans Training Manual Standard Operating Procedures, if available Please read the following statement carefully and sign below where indicated. If a policy is issued this signed statement will be attached to the policy. The insured hereby acknowledges that he/she/it is aware that the limit of liability contained in the cpl policy shall be reduced, and may be completely exhausted, by the costs of legal defense and, in such event, the insurer shall not be liable for the costs of legal defense or for the amount of any judgment or settlement or cleanup costs to the extent that such exceeds the limit of liability of this policy. The insured hereby further acknowledges that he/she/it is aware that legal defense costs that are incurred shall be applied against the deductible amount. Declaration The applicant represents that the above statements and facts are true and that no material facts have been suppressed or misstated. Completion of this form does not bind coverage. Applicant's acceptance of Insurer's quotation and Insurer's written agreement to be bound is required to bind coverage and to issue policy. It is agreed that this form shall be the basis of the contract should a policy be issued, and will be attached to the policy. All written statements and materials furnished to the Insurer in conjunction with this application are hereby incorporated by reference into this application and made apart hereof. If an order is received, the application is attached to the policy so it is necessary that all questions be answered in detail. Signed Title (authorised signatory of the Insured) Company Date American International Group, Inc. (AIG) is a leading international insurance organisation serving customers in more than 130 countries and jurisdictions. AIG is the marketing name for the worldwide property-casualty, life and retirement, and general insurance operations of American International Group, Inc. This material is for information purposes. Products and services are written or provided by subsidiaries or affiliates of American International Group, Inc. and may not be available in every jurisdiction. For additional information, please visit our website at Registered in England: company number Registered address: The AIG Building, 58 Fenchurch Street, London EC3M 4AB AIG Europe Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and Prudential Regulation Authority. 8 of 8