Pollution Liability For Farms & Ranches including Transportation Pollution Liability

Transcription

1 Application Sponsored by Anchor Bay Insurance Managers, Inc. Post Office Box # 2510 / Silverdale, WA Phone: / Fax: Web Site: SurplusLines.com Submit Applications To: Applications@SurplusLines.com Pollution Liability For Farms & Ranches including Transportation Pollution Liability Pollution Liability and related coverages for Farm & Ranch Pollution Exposures Instructions Please include the following 1. Statement of Qualifications / resumes 4. Standard contracts / subcontracts with this application: 2. Financials 5. Table of contents from in-house 3. Three years of currently valued loss runs health and safety procedures Agency Information Name: Address: City: State: Zip: Phone: Fax: Website: Producer Name: Phone: Assistant Name: Phone: Applicant Information Business Name: Federal Tax ID#: Legal Name: EPA ID#: Type of Entity: Sole Partnership Joint Venture Corporation LLC Other Mailing Address: City: State: Zip: Physical Address: City: State: Zip: Phone: Fax: Website: Owner or Manager: Phone: Accounting Contact: Phone: Inspection Contact: Phone: Date Applicant was established: For how many years has Applicant performed environmental services? Loss History Currently Valued Loss Runs: Attached Requested Provide prior to binding Not available Total claims, lawsuits and/or events or conditions or incidents in the past 5 years that may lead to a future claim or lawsuit: By attachment, please describe fully and completely, any environmental claims which you have been involved in None during the last five years, including claims related to drift and overspray of chemicals and fertilizer. By attachment, please describe fully and completely, any environmental incidents (spills or releases) which have None occurred in the past five years. Total paid and reserved for those claims (including defense): $ (Please attach loss runs or a complete description of all) Please provide details of any claims paid or reserved, including defense, that exceed $5,000 1

2 Coverage Information Proposed Effective Date: Proposed Expiration Date: Need by Date: Pollution Liability Current Coverage is: Occurrence Form Claims Made Form Retroactive Date: / / Deductible / SIR: $ Limits Current Limits Proposed Limits Per Pollution Incident Annual Aggregate If converting from Claims Made to Occurrence, do you wish to include a quote for nose coverage? Yes No Defense is currently Included in the policy limit Unlimited, outside the limit A separate limit of: $ /$ Requested Coverage Enhancements: Does current coverage provide Time Element First Party Cleanup Discovery coverage Yes No Does current coverage provide Time Element Third Party Liability coverage Yes No Prior Carrier Information Year Category Commercial Pollution Liability Contractor s Commercial Excess Liability General Liability (Fixed Site) Pollution Liability Automobile Carrier Policy Number Premium Effective Date Expiration Date Retroactive Date Carrier Policy Number Premium Effective Date Expiration Date Retroactive Date Carrier Policy Number Premium Effective Date Expiration Date Retroactive Date 2

3 General Information Has any carrier ever declined, refused to renew or cancelled any insurance that had been issued to Applicant, a predecessor in business, or to a person, firm, organization or joint venture managed by the General Manager, Managing Partner or Joint Venturer or President named above? Yes No If Yes, reason: Non-Payment Agent no longer represents carrier Underwriting Reason (Describe the condition and what has been done to alleviate the problem): Gross Revenue: $ For the upcoming policy year $ For the current policy year $ For the 1st prior policy year $ For the 2nd prior policy year Has Applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy, judgment or lien during the last five (5) years? Yes No If Yes, please provide the following: Occurrence Date Explanation Resolution Resolution Date Do you wish to include Pollution coverage for one or more storage tanks? If Yes, please visit our environmental page for the appropriate storage tank application. In the past five years, have you been cited (whether or not prosecuted) for any violation of any standard law relating to the release of a substance into the environment? If Yes please provide full and complete details by attachment. Yes Yes No No Marketing Information Do you control the account now? Yes No or do you have any inside edge? Yes No If Yes, describe: Price and Terms needed to write the account: Operations & Exposures Loc # Total Acres Address and Description of Operations (Including Type of Crop) Own or Lease?

4 Operations & Exposures (continued) Does Applicant raise livestock or poultry at these locations? Loc # Type of Livestock Housed how Capacity? 1 Confined feedlot Pasture Range 2 Confined feedlot Pasture Range 3 Confined feedlot Pasture Range 4 Confined feedlot Pasture Range 5 Confined feedlot Pasture Range 6 Confined feedlot Pasture Range 7 Confined feedlot Pasture Range 8 Confined feedlot Pasture Range 9 Confined feedlot Pasture Range 10 Confined feedlot Pasture Range If the livestock is housed in confinement or a feedlot, describe how the waste is handled and disposed of: Loc # Description Are untreated livestock wastes discharged via ditch or other man-made conveyance to any waters? Loc # Yes or No If Yes into which waters? 1 Yes No 2 Yes No 3 Yes No 4 Yes No 5 Yes No 6 Yes No 7 Yes No 8 Yes No 9 Yes No 10 Yes No Does Applicant have a comprehensive nutrient plan in place at confinement feedlot locations? Yes N If Yes, attach a copy Do you generate, store, handle or dispose of any potential hazardous materials at any of these locations? Yes No 4

5 Operations & Exposures (continued) Does the Applicant do any aerial application of chemicals or fertilizers? Does the Applicant purchase or subcontract out for aerial application services? If Yes to either question: how many acres are treated each year? How many mobile field tanks of up to 2,000 pounds does the Applicant own? Describe storage and disposal of chemicals and fertilizers: Yes Yes No No Does the Applicant have: A written Safety Program A written Respiratory Protection Program A written Hazard Communication Program (If Yes to any, attach a copy) Approximate distance to groundwater at this site? Is the Applicant aware of any natural resource damage, assessments or threats to endangered species, protective habitat, or other similar resources? If Yes, describe: Yes No Yes No Yes No Yes No Is there any known or suspected soil and / or water contamination at the site or at an owned or unowned adjacent site that may impact this site? If Yes, describe: Has an Environmental Phase I or Phase II been completed on this facility in the past five (5) years? If there is no known or suspected soil and / or water contamination at this site, then describe the results. If there is known or suspected soil and / or water contamination at this site, then please attach a copy of the Phase I or Phase II report. Yes Yes No No Please complete for all specialties. Services Total Projected Gross Receipts Total From Your Work Total From Subcontracted Work Projected Acres Chemical Application Fertilizer Application (non-manure) Manure Applciation Planting Tillage Harvest Other (please specify) Other (please specify) Total 5

6 Please complete the following (a complete copy of the GL application schedule may be sufficient): Projected Description of All Other Operations Projected Payroll Subcontract Cost 1. Projected Revenue Totals for all other operations: Transportation Pollution Liability (TPL) Supplement Operations, Exposures & Controls Does Applicant haul or transport materials for others? Yes No Does trip leasing comprise of more than 5% of gross receipts? Yes No Are the number of units operated affected by seasonal operations? Yes No Does the Applicant assume ownership of any product they haul? If Yes, describe: Yes No What is the driver population: Full Time Employed Owner Operator Part Time Employed Other(describe) Does the Applicant haul any of the following: Asbestos Waste Yes No Radioactive Waste Yes No Spent Munitions Yes No If Yes to any, describe Owners Operators Are the owner operators exclusively hauling for the Applicant under written contract? Yes If No, explain: No Does the contract require non-trucking liability to be in place? If No, explain: Yes No 6

7 Operations, Exposures & Controls (continued) Are owner-operators subject to the same hiring and training standards as company drivers? Yes No If No, explain: Are owner operators held to the same equipment maintenance standards as company equipment? Yes No If No, explain: Vehicle Summary Power Equipment Company Owned Owner/ Operator Number Operation Radius Cargo Tank Capacity Tractors Heavy Trucks Medium Trucks Light / Service Private Passenger Tank Trucks (500 Gallons or less) Tank Trucks (3,000 Gallons or less) Tank Trailers (3,000 Gallons or less) Tank Trucks (over 3,000 Gallons ) Tank Trailers (over 3,000 Gallons) Van Dump Truck Refrigerated Trailers Box Trailers Garbage Trucks Pickup Trucks Stake & Flat Bed Trucks Vacuum Trucks Flat Bed Trailers Other (describe) Does the Applicant pull double trailers? Yes No Does the Applicant pull triple trailers? Yes No 7

8 Operations, Exposures & Controls (continued) Cargo Transported (check all that apply) Cargo % of Cargo Packaged % Drummed Bulk Asbestos Containing Material Contaminated Soil Construction Materials / Debris Demolition Debris Explosives (ABC) Fertilizer Gasoline / Diesel Grease Hazardous Chemicals Herbicides Insecticides Lab Chemicals Lab Packs Lead Containing Material Manure Medical Waste Paint/Paint Thinners Petroleum Products Radioactive Meat Recycled Material Non Hazardous Recycled Material Hazardous Other (describe) Other (describe) Work Practices Do all drivers have their CDL with the hazardous materials endorsement? If No, explain; Yes No Describe the driver selection process as follows: Criminal Background Check Yes No MVR Check Yes No Reference Check Yes No Road Test Yes No Written Application Yes No Who is responsible for screening drivers? Is there a formalized program for all units? Yes No Is the Applicant responsible for owner operator equipment? Yes No Are vehicles equipped with theft alarms? Yes No Are vehicles locked while unattended? Yes No 8

9 Operations, Exposures & Controls (continued) Are vehicles left loaded overnight? Yes No Are passengers allowed in company insured vehicles? Yes No If Yes, is management approval required and are liability release forms obtained? Yes No Training and Safety Is there a full time safety director? Yes No If Yes, provide name, years of service and pertinent background information: Do drivers receive training for tie-down and weight distribution procedures for flat bed operations? Yes No How often are drivers safety meetings held? Who holds the safety meetings? Are all drivers required to attend? Yes No Is there a record of attendance? Yes No Are the following programs and procedures formalized? Safety Programs Yes No Product Handling Procedures Yes No Driver Hiring Procedures Yes No Training Programs Yes No Is there a written disciplinary program? Yes No Are driver hiring criteria formalized? Yes No Does the Applicant have a safety incentive program for drivers? If Yes, describe: Yes No Territory Please indicate the percentage of units operating in each of the metropolitan areas designated below. State State State State State % Atlanta % Dallas % Little Rock % New Orleans % Richmond % Baltimore % Denver % Los Angeles % New York City % St. Louis % Boston % Detroit % Louisville % Oklahoma City % Salt Lake City % Buffalo % Hartford % Memphis % Omaha % San Diego % Charlotte % Houston % Miami % Phoenix % San Francisco % Chicago % Indianapolis % Milwaukee % Philadelphia % Seattle % Cincinnati % Jacksonville % Minneapolis % Pittsburgh % Tulsa % Cleveland % Kansas City % Nashville % Portland, OR % Washington DC Additional Insureds Name: Address: City, State, Zip: Insurable Interest:: Lender Landlord Public Entity Other: Loan / Permit #: Name: Address: City, State, Zip: Insurable Interest:: Lender Landlord Public Entity Other: Loan / Permit #: 9

10 Comments & Explanations Warranty and Signature As a condition precedent to coverage, the undersigned warrants that the information contained herein, including information contained in any and all attachments, is true, complete and free of pertinent omissions and material misrepresentations, and that he/she knows of no claims, lawsuits filed or pending, or events or conditions or incidents which may lead to a future claim or lawsuit. / / Applicant s Signature Applicant s Printed Name Applicant s Title Date 10