3 Easy Steps
1) Fill out application online by tabbing through the fields.
2) Email:
 File Menu > Send to >Mail Recipient (as attachment)
 To: ACE Underwriter Name
3) OR, Fax:
1) Save application to your hard drive (File > Save As >)
2) Fax To: ACE U/W Fax Number
Any questions please call: UW Phone Number

SM
Company: Broker:
Address:
Contact:
E-Mail:
Address:
Contact:
E-Mail:
Phone: Phone:
Fax:
Dunn & Bradstree t
#:
Fax:
Years in Business:
Individual Partnership
Type of Business: Manufacturing
General Information
Corporation
Wholesale/Distributor
JV
Retail
Other
Other
:
:
Intended Inception Date: Limits of Liability Requested: $ Each Occurrence $ Aggregate
$ Retention (Deductible or SIR)
Do you purchase or carry any environmental insurance currently? Please describe the program structure.
Submission Data to include:

Completed CGL ACORD Application

Currently Valued (less than six months) 5 years of historical loss experience

5 Years of historical exposure (sales, units, payroll, etc.)

Description of products, services, operations, and primary customer base

List of Named Insured and corresponding description of operations with address

Any products or product components or chemicals mixed, manufactured, packaged and or purchased outside of the U.S.

Safety, Loss Control and Quality Control Measures in place to ensure specifications are followed

Copies of expressed or implied product or service warrantees in place or anticipated

Any special contractual arrangements pertaining to indemnity or hold harmless agreement to a third party, past or present.
1906 version 1-29-2008 Page 1 of 7


Provide Most Current two years of Audited Financial Statements
Have you ever recalled a product? Yes ____ No____ Explain:
1) Please provide additional details for each Product listed above that is designed to your Company ’s specifications.
2) Are any Products to be insured under this coverage used in the following industries? Check all that apply.
Aircraft / Aerospace
Motor vehicles
Watercraft / Offshore
Medical or Pharmaceutical
Cosmetics
None of the above
If Yes, please describe in detail.
3) Are any Foreign Supplier-provided Products to be insured under this coverage tested and certified for use by your Company or others? If yes, please describe.
4) Are any Foreign Supplier-provided Products to be insured under this coverage subject to review and approval by your Company to meet industry standards?
If Yes, has ISO 9000 certification been completed?
5) Does your Company maintain and service any of the Foreign Supplier-provided Products that are to be insured under this coverage? If Yes, please describe.
6) Please describe the operations of the Insured:
7) Company Sales History:
Year :
Year :
Year :
Year :
Year :
Anticipated Sales for New Policy Year: $______________
8) Mark below the coverage for which you are requesting and complete the retention amount desired for each line of coverage.
Retention
On-Site Pollution for: o Bodily Injury o Property Damage o Third Party Clean Up of new conditions o First Party Discovery Clean Up of new conditions
$________
$________
$________
$________
1906 version 1-29-2008 Page 2 of 7

Retention
Off-Site Pollution Coverage for: o Bodily Injury o Property Damage o Third Party Clean Up of new conditions o First Party Discovery Clean Up of new conditions
$________
$________
$________
$________
9) Do you wish to purchase coverage for Non-Owned Disposal Site(s)? If so, please provide the list of sites to be covered.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
10) Do wish to coverage for above ground storage tank releases? If so, please provide us with a list of tank sites.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
11) Do you wish to purchase coverage for underground storage tanks? If so, please provide list of tanks.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
12) Do you wish coverage for Pollution Seal conditions from transported cargo? If so, please provide list of vehicles.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
1906 version 1-29-2008 Page 3 of 7

PREMISES SECTION – Pollution
These questions apply to each and every location that is to be insured. Feel free to complete this form section for each location to be covered.
1. How long has the Named Insured been in business at this location?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
2. Describe the activities and operations at this location both previous and current for as far back as is known. List and describe prior companies and their operations at this location.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
YES NO
3. Is the location fenced?
4. Is the location equipped with Emergency Lighting?
5. Is the location sprinklered?
6. Are third parties required to sign in when entering the premises?
7. Are third parties escorted when entering the premises?
8. Are third parties required to personal protective gear?
9. Are any tours conducted on the premises?
If yes, how frequently?
How has your company addressed risks associated with terrorism:
____
____
____
____
____
____
____
POLLUTION COVERAGE QUESTIONS
1. Has the prospective insured 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
____
____
____
____
____
____
____
If Yes, please provide details:
2. Has the applicant (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?
_____Yes _____No
If Yes, please provide details:
3. List all Claims made against you during the last five years for clean up or response ac tion “Toxic Tort” or other bodily injury, or property damage resulting from the release of hazardous substances, hazardous waste, or other pollutants, from any location owned or operated by, into the environment.
1906 version 1-29-2008 Page 4 of 7

If none, please so state. If yes, please provide details.
4. At the time of signing this application, do you or organization know of any facts or circumstances which may give rise to or result in claim or series of claims being asserted against your company for environmental clean up response, or for bodily injury or property damage arising from the release of pollutants into the environment? ____Yes ____No.
If yes, please provide details:
Within the past five (5) years has the applicant purchased this type of insurance coverage? YES NO
If “Yes”, please provide information regarding any such coverage and all available loss information.
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
Does the applicant or other party to the proposed insurance have knowledge of any pollution conditions at any of the proposed covered locations? YES NO
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
If there is an existing Pollution Legal Liability Policy in place are there any coverage restrictions and or sites that
YES NO are excluded?
If yes, please explain the rationale and what those restrictions are on the current policy.
Please describe any loss in excess of $25,000 (incurred expense).
Is additional information attached? Yes
For the desired Pollution Coverages what retro date is being requested? ______________. Is this date consistent with the current Pollution coverage in place? ___________
1906 version 1-29-2008 Page 5 of 7

CGL Policy Coverage Section
1. Describe the manufacturing process or services rendered by your organization:
2.
3.
Identify the industry and names of your largest customers:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Are your products modified and re-packaged by any other party including by your customers?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. Describe the controls in place to ensure product consistency and quality throughout the manufacturing process:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
5. Do you require and obtain Certificates of Insurance and have minimum limits of insurance from your suppliers? __________. What are your insurance Requirements?
____________________________________________________________________________________
____________________________________________________________________________________
_______________________________________________________________________
6. Do you utilize Indemnity and or Hold Harmless Agreements?
_______________________________
Please provide us with copies.
7. Have you made any acquisitions or divestures in the last five years?_______________________. Did the sale or acquisition include liabilities?____________. Please describe:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________
8. Do you have any potential acquisitions in coming 12 months?_________ If so, please describe:
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________
9. Do you have new products or services that your firm is contemplating?__________. If so, please describe: ____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
10. Do you have an investigation process in place for determining product failure? ____________
If so, please describe:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please furnish us with no less than five years of GL and Pollution claims reflecting by policy year, claim count, incurred, paid, reserved and segregating between Pollution and CGL losses as well as ALAE. A currently valued carrier or TPA loss runs is required prior to any quote release.
1906 version 1-29-2008 Page 6 of 7

Please express additional comments and or pertinent underwriting information that you wish to share regarding your organization and coverage you are seeking for ACE quote.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I certify that I have authority to provide the requested information above on behalf of the applicant and that the information provided above is compete and accurate as of the date reflected below next to my signature.
Signed Title Date
1906 version 1-29-2008 Page 7 of 7