ACE INA Insurance
Assurance ACE INA
ACE PaC SM - Pollution and Casualty Insurance
Coverage Application
Instructions:
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Please type in the gray fields or print and write your responses.
Answer ALL questions completely, leaving no blanks. If any questions, or part
thereof, do not apply, indicate as “Not Applicable”.
Provide any supporting information on a separate sheet using your letterhead
and reference the applicable question number.
This form must be completed, dated and signed by a Principal, Officer or Risk
Manager of your Company.
Required Submission Information: Please submit the following additional information
with your completed application.
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Completed Ace Commercial General Liability Application (including Auto and
Umbrella as applicable).
Please provide us with 5 years of currently valued (less than six months)
ground-up loss detail and summary for General Liability and Pollution Liability.
Please provide copies of the Applicant’s past two (2) years audited financial
statements.
Applicant Information:
Name of
Applicant
Mailing
Address
City,
Province,
Postal Code
Principal
Contact
E-mail Address
Company Type:
Telephone:
Corporation
Partnership
Joint Venture
LLC/LLP
Other:
Website:
Year
Established:
©2013
Page 1 of 8
EXISTING COVERAGE
General Liability
Pollution Liability
Umbrella
Limits of Insurance:
Each Occurrence $
General Aggregate: $
Products-Completed
Operations Aggregate: $
Limits of Insurance:
Each Pollution Condition
$
Aggregate: $
Retention:
SIR or
Deductible - $
None
SIR $
Limits of Insurance:
Each Occurrence: $
General Aggregate: $
Products-Completed Operations
Aggregate:
$
Underlying:
Coverage Form:
Occurrence
Claims Made
Coverage Form:
Occurrence
Claims Made
Carrier:
REQUESTED COVERAGE
AL
Limits:
$
Premium:
$
EL
$
$
Foreign
$
$
- Enter limits and retention desired for selected coverages
Proposed Policy Term:
to
General Liability
Each Occurrence:
General Aggregate:
Products-Completed Operations
Aggregate:
Limits of
Insurance:
$
$
$
Retention
Limits of Insurance
$
$
Retention
SIR: $
SIR $
Deductible $
None
Pollution Liability
Each Pollution Condition:
Aggregate:
Premises, Transportation and Disposal Site Pollution
Liability
E.1 On-Site Third Party Bodily Injury and Property
Damage
E.2 Off-Site Third Party BI, PD and Remediation Costs
E.3 On-Site and Off-Site Government Action
E.4 Off-Site Transportation Pollution Liability
E.5 Off-Site Non Owned Disposal Site Liability
Complete Schedule A
below
Complete Schedule B
below
F. Sudden and Accidental Pollution Liability
G. Pollution Discovery Clean Up
General Pollution Liability
H.1 Products Pollution
H.2 Hostile Fire and Building Heating Equipment
H.3 Contractor’s Pollution Liability
Storage Tank Liability
Complete Schedule C
below
©2013
Page 2 of 8
Comments:
Total Gross Revenue
Year:
$
Year:
$
Year:
$
Year:
$
Estimated for Proposed Policy
Year:
$
GENERAL LIABILITY AND PRODUCTS LIABILITY EXPOSURES
Named Insured
Description of Operations: including Manufacturing
Process, Products and or Services Provided
Estimated Revenue
$
$
$
$
Other:
Please indicate Yes or No as applicable and provide details in the box below each
question.
1
Do you require and obtain Certificates of Insurance and have minimum
limits of insurance from your suppliers? What are your insurance
requirements?
Yes
No
Response:
2
Do you require Additional Insured status from your suppliers?
Yes
No
Response:
3
Do you enter into indemnity and or hold harmless agreements? (Please
provide us with copies.)
Yes
No
Response:
4
Have you made any acquisitions or divestures in the last five years?
Yes
No
Response:
5
What new products or services is your firm contemplating?
Yes
No
Response:
©2013
Page 3 of 8
6
Please identify the industry and name of your largest customers:
Response:
7
Are your products modified and re-packaged by any other party including
by your customers?
Yes
No
Response:
8
Do you manufacture to the specifications of others? What percentage of
your manufacturing is toll manufacturing?
Yes
No
Response:
9
What controls are in place to ensure product consistency and quality
throughout the manufacturing process?
Yes
No
Response:
10
Do you have an investigation process in place for determining the cause
of product failure?
Yes
No
Response:
11
Yes
No
Have you ever recalled a product?
Response:
12
Are any Products to be insured under this coverage
used in the following industries?
Check all that apply.
13
Aircraft / Aerospace
Motor vehicles
Watercraft / Offshore
Medical or Pharmaceutical
Cosmetics
None of the above
Do you import products or component parts (Foreign supplier-provided
products)?
Yes
No
Response:
14
How has your company addressed risks associated with terrorism?
©2013
Page 4 of 8
Response:
15
ADDITIONAL COMMENTS
PREMISES POLLUTION LIABILITY EXPOSURES
Location Address
Years at
this
Location
Past and Current Operations at this
Location (including prior companies’
operations)
1
2
3
4
5
Complete for Locations listed above. Please indicate Yes or No as applicable and
provide details in the box below each question.
16
Within the past five (5) years has the applicant purchased this type of
insurance coverage? Please provide information regarding any such coverage and
all available loss information.
Yes
No
Response:
17
Yes
No
Are location(s) fenced?
Response:
18
Are location(s) equipped with emergency lighting?
Yes
No
Response:
19
Yes
No
Are location(s) sprinklered?
Response:
©2013
Page 5 of 8
20
Yes
No
Are third parties required to sign in when entering the premises?
Response:
21
Yes
No
Are third parties escorted while on the premises?
Response:
22
Yes
No
Are third parties required to wear personal protective gear?
Response:
23
Yes
No
Are any tours conducted on the premises? If yes, how frequently?
Response:
24
Yes
No
Do you have tenants at any of the locations listed above?
Response:
25
Have you (persons or organization), during the last five years, had any
reportable releases or spills of hazardous substances, hazardous waste of any
pollutants, as defined by applicable environmental statutes or regulations?
Yes
No
Response:
26
Yes
No
Have you (persons and or organization), during the last five years, been
prosecuted or are you currently being prosecuted for contravention of any
standard or law relating to release or threatened release of a hazardous
material, hazardous waste or any other pollutant from any location owned or
operated by you?
Response:
Schedule A – Off Site Transportation Exposure – Complete if Coverage E.4 is
requested
Name and Address of Common
Carrier
Average Number of Monthly
Shipments
Are you listed as an
Additional Insured for
Pollution coverage?
Yes
No
©2013
Page 6 of 8
Yes
No
Yes
No
Schedule B – Non Owned Disposal Sites – Complete if Coverage E.5 is requested
Site
Address
1
2
3
4
Schedule C Tanks
Complete or attach Tank Inventory List with the following information
if coverage is requested.
Type (AST or UST)
AGE
Construction
Size
Contents
Select
Select
Select
Additional Claims Information
Please indicate Yes or No as applicable and provide details in the box below each
question.
27
Within the past five (5) years have any claims been made or legal actions
(including any regulatory proceedings) been brought against the applicant or
other party to the proposed insurance?
Yes
No
Response:
28
Yes
No
Does the applicant or other party to the proposed insurance have knowledge
of any pollution conditions at any of the proposed covered locations?
Response:
29
At the time of signing this application, are you aware of any circumstances
that may reasonably be expected to give rise to a claim against any insured?
Yes
No
Response:
30
Please describe any loss in excess of $25,000 total incurred:
©2013
Mark if
None
Page 7 of 8
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 SIGNING THIS APPLICATION, THE APPLICANT WARRANTS TO THE COMPANY THAT ALL
STATEMENTS MADE IN THIS APPLICATION INCLUDING ATTACHMENTS, ABOUT THE APPLICANT AND
ITS 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.
THE UNDERSIGNED ACKNOWLEDGES AND UNDERSTANDS THAT ANY PERSONAL INFORMATION
CONTAINED IN THIS APPLICATION HAS BEEN COLLECTED IN ACCORDANCE WITH ALL APPLICABLE
PRIVACY LEGISLATION.
Signature of Authorized Applicant
Signature of Broker/Agent
Print Name
Print Name
Title
Date
Date
Signed by Licensed Resident Agent
(Where Required By Law)
©2013
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