Illinois Union Insurance Company
Contractors Pollution
Liability
Project-Specific Insurance
Policies
Occurrence-Based Coverage
Application
Instructions:





Please type or print clearly.
Answer ALL questions completely, leaving no blanks. If any questions, or part thereof, do not apply, print
“N/A” in the space.
Provide any supporting information on a separate sheet using your letterhead and reference the applicable
question number.
Check Yes or No answers.
This form must be completed, dated and signed by a principal of your Company.
Required Attachments:


Please provide a copy of your Statement of Qualifications (should include, at a minimum, key personnel
resumes, representative project listing, etc.).
Please provide copies of your past two (2) years of audited financial statements and annual reports.
NOTICE TO APPLICANT: The coverage applied for is solely as stated in the policy and any endorsement
thereto, which provides coverage on an OCCURRENCE BASIS, thereby covering loss that occurs during
the policy period arising from pollution conditions resulting from covered operations that are performed
during the policy period. This policy also provides coverage for emergency response costs that is limited
by SPECIFIC REPORTING CRITERIA, which covers only emergency response costs reported to the insurer,
in writing, within the specific timing requirements identified in this policy, subject to the policy provisions.
TYPE OF PROJECT COVERAGE:
OCIP (Owner-Controlled Insurance Program)
CCIP (Contractor-Controlled Insurance Program)
PROJECT (Non-Wrap Up)
1. Name of Applicant:
Principal Contact:
E-mail Address:
Mailing Address:
Telephone #:
URL:
Company is:
Fax #:
http://
Date Established:
Corporation
Partnership
Joint Venture
LLC/LLP
Other:
PF-33669 (09/10)
© 2010
Page 1 of 5
2. Name / Location of Project:
New Construction
Renovation / Addition / Retrofit
3. General Scope of Work:
4. Estimated Construction Values: ___________________
5. Project Term:
Estimated Start Date: ___________________ Estimated Completion Date: _____________________
6. Extended Reporting Period (claims-made only)
1 year
2 years
3 years
none
7. Completed Operations Coverage (occurrence-based only)
1 year
2 years
3 years
none
8. Limit Options Requested:
$1M / $1M
$3M / $3M
$5M / $5M
$10M/ $10M
Other __________
9. Self Insured Retention Options Requested:
$25,000
$100,000
$50,000
$250,000
$500,000
Other __________
10. Is Pollution Coverage required by written contract?
YES
NO
11. Is Mold Liability required?
YES
NO
(If Yes is checked, please provide a copy of the designated Mold Prevention Plan to be used for the Project)
12. Is coverage to be placed on a Wrap-Up basis?
YES
If Yes, who will secure the program?
Owner
NO
Contractor
13. Please provide the estimated sales associated with the following activities for the Project:
Activity:
Sales
% Sub-contracted
Environmental Professional
Environmental engineering
RI/FS
Project Management
Environmental audits/ assessments
Phase I/ real estate audits
PF-33669 (09/10)
© 2010
Page 2 of 5
Soil/ water testing
Lab testing/ analysis
Asbestos/ lead design
Tank system design/ testing
Regulatory compliance/ permitting
Waste brokering
Health & safety training
Industrial hygiene/ mold consulting
Other (explain)
Non-environmental Professional
Construction Management
Process design
Non-environmental engineering
Geotechnical
HVAC design/ mechanical engineering
Civil engineering
Other (explain)
Total professional:
Environmental Contracting
Soil excavation
Soil/ groundwater treatment
Bioremediation
Underground/ subsurface remediation
Dredging
PCB handling
Emergency spill response
Landfill construction
Liner installation
Monitoring well drilling
Potable well drilling
Soil/ groundwater boring
Lab packing
UST installation
UST removal
Tank cleaning
Pipeline installation
PF-33669 (09/10)
© 2010
Page 3 of 5
Pipeline/ sewer/ septic maintenance
Industrial cleaning
Hydroblasting
Demolition
Asbestos/Lead Abatement
Mold remediation services
Other (explain)
Non-Environmental Contracting
Electrical
HVAC
Plumbing
Water/ sewer
Heavy Highway / Bridge
Road construction/ maintenance
Excavation
Site development/ grading
Concrete work
General Building Construction
Other (explain)
Total contracting:
COMBINED TOTAL:
14. Will Standard contracts be used with subcontractors?
YES
NO
a. If yes, do they contain hold harmless or indemnification agreements in favor of your Company?
YES
NO
15. Describe current liability program for Project:
Coverage:
Carrier:
Limit:
Expiration:
Retroactive
date:
Premium:
General Liability
Umbrella
Workers Compensation
16. Has the applicant or any other party to the proposed insurance ever been
subject to disciplinary action as a result of their professional activities?
i.
YES
NO
If yes, please attach a written description/explanation.
17. Within the past five (5) years have any claims been made or legal actions
(including any regulatory proceedings) been brought against the applicant
PF-33669 (09/10)
© 2010
Page 4 of 5
or other party to the proposed insurance?
i.
NO
YES
NO
YES
NO
If yes, please attach a written description/explanation.
20. 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?*
i.
YES
If yes, please attach a written description/explanation.
19. Does the applicant or other party to the proposed insurance have knowledge
of injury to people or damage to property during the last five (5) years on or at
projects where the applicant performed professional services or contracting
operations?
i.
NO
If yes, please attach a written description/explanation.
18. Within the past five (5) years has the applicant or other party to the proposed
insurance been involved in any pollution incidents on or at projects where the
applicant performed professional services or contracting operations?
i.
YES
If yes, please attach a written description/explanation.
*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.
Signature of Authorized Applicant
Signature of Broker/Agent
Print Name
Print Name
Title
Date
Date
Signed by Licensed Resident Agent
(Where Required By Law)
PF-33669 (09/10)
© 2010
Page 5 of 5