Underground Storage Tank Pollution Liability Application

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 Underground Storage Tank Pollution Liability Application Third Party Pollution and On Site Cleanup Instructions Please include the following with this application: 1. Financials 2. Three years of currently valued loss runs Agency Information Name: Address: City: State: Zip: Phone: Fax: Website: Producer Name: Phone: Assistant Name: Phone: Applicant Information New Business Renewal 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: Environmental Manager: Phone: Accounting Contact: Phone: Inspection Contact: Phone: Date Applicant was established: Years at this location: 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? If Yes, reason: n-payment Agent no longer represents carrier Underwriting Reason (Describe the condition and what has been done to alleviate the problem): Gross Revenue: $ For the upcoming policy year $ For the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 1

2 General Information (continued) Has Applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy, judgment or lien during the last five (5) years? If Yes, please provide the following: Occurrence Date Explanation Resolution Resolution Date Do you wish to include Pollution coverage for any other exposures? If Yes, please visit our environmental page for the appropriate contracting Pollution application Has there been any federal or state reportable discharge, dispersal, escape, leak, release or spill at this location in the past 10 years? If Yes, has the remediation been completed? (If Yes, provide case closure letter) Coverage Information Proposed Effective Date: Proposed Expiration Date: Need by Date: Which coverages is the Applicant requesting? On Site Pollution Liability Third Party Pollution Liability Both Desired Policy Term: One Year Two Years Three Years Other: Pollution Liability Current Coverage is: Occurrence Form Claims Made Form Retroactive Date: / / Deductible: $ Current Limits: $ Requested Limits: $ Requested Deductible / SIR: $ If converting from Claims Made to Occurrence, do you wish to include a quote for nose coverage? Defense is currently Included in the policy limit Unlimited, outside the limit A separate limit of: $ / $ Requested Coverage Enhancements: Prior Carrier Information Pollution Liability Category Carrier Policy Number Premium Effective Date Expiration Date Retroactive Date Loss History Currently Valued Loss Runs: Attached Requested Provide prior to binding t 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: Total paid and reserved for those claims (including defense): $ (Please attach loss runs or a complete description of all) In the Comments Section on the last page of this application, please provide complete details of any claims paid or reserved, including defense, that exceed $5,000. 2

3 Location # Please complete for each location for which coverage is sought Address / Location: Complete the following Underground Tank Schedule Tank Information Tank # 1 Tank # 2 Tank # 3 Tank # 4 Tank # 5 Tank # 6 Contents Date Installed Capacity Contents Regular Gasoline, Ulneaded Gasoline, Diesel, Kerosene, New Oil, Waste Oil, Heating Oil or Specify Tank Construction Tank # 1 Tank # 2 Tank # 3 Tank # 4 Tank # 5 Tank # 6 Steel Single Wall Steel Double Wall STIP-3 Single Wall STIP-3 Double Wall Fiberglass Single Wall Fiberglass Double Wall Fiberglass Clad Steel Single Wall Fiberglass Clad Double Wall Fiberglass Lined Date Lined Tank Protection Tank # 1 Tank # 2 Tank # 3 Tank # 4 Tank # 5 Tank # 6 None Cathodic Protection Painted/Coated Concrete Diking Earthen Diking Tank Leak Detection Tank # 1 Tank # 2 Tank # 3 Tank # 4 Tank # 5 Tank # 6 None Automatic Tank Gauge Statistical Inventory Control Dipstick Monitoring Interstitial Monitoring Visual Groundwater Monitoring Oil/Water Separator Vapor Monitoring Spill/Overflow Protection Date of Last Tightness Test: Please attach a copy of the certificate. 3

4 Location # (continued) Please complete for each location for which coverage is sought Complete the following Underground Tank Schedule Piping Information Tank # 1 Tank # 2 Tank # 3 Tank # 4 Tank # 5 Tank # 6 Piping Installation Date % Above Ground Piping Construction Tank # 1 Tank # 2 Tank # 3 Tank # 4 Tank # 5 Tank # 6 Steel Single Wall Steel Double Wall Fiberglass/Flexible Single Wall Fiberglass/Flexible Double Wall Pipe Protection Tank # 1 Tank # 2 Tank # 3 Tank # 4 Tank # 5 Tank # 6 None Cathodic Other Pipe Leak Detection Tank # 1 Tank # 2 Tank # 3 Tank # 4 Tank # 5 Tank # 6 None Electronic Interstitial Other Dispenser Method Tank # 1 Tank # 2 Tank # 3 Tank # 4 Tank # 5 Tank # 6 Suction Pressure Gravity Have any underground/aboveground tanks been removed, abandoned or closed in place? If Yes, then has a regulatory agency issued a No Further Action letter or given some other form of approval for the closure? (Please attach a copy of documentation.) Is there a history of leakage or releases at this location relating to storage tanks not listed above? If Yes, then describe: Does the location owner also own the underground tanks? If No, then describe relationship: Are there any plans to close, remove or upgrade any tanks at any facility in the next 18 months? If Yes, then describe: 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: 4

5 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 #: Marketing Information Do you control the account now? or do you have any inside edge? If Yes, describe: Price and Terms needed to write the account: Additional Comments and 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 5