XL Catlin Facilities Pollution
Fixed Base Operator (FBO) Environmental Coverage Application
XL Insurance Company SE • 100 Yonge Street, Suite 1802, Toronto, Ontario, M5C 2W1
Tel: 416-928-5586
Fax: 416-928-8858
www.xlinsurance.com/environmental
THIS APPLICATION IS FOR A “CLAIMS-MADE AND REPORTED” POLLUTION AND
REMEDIATION LEGAL LIABILITY POLICY.
PLEASE READ THE APPLICANT INSTRUCTIONS BELOW CAREFULLY AND FILL OUT THIS
APPLICATION COMPLETELY.
APPLICANT INSTRUCTIONS:
1.
Answer all questions; leave no blank spaces.
2.
If any questions do not apply, or the answer is “No”, please indicate.
3.
If requesting coverage for multiple locations, answer the questions that pertain to any of the locations
and attach a location schedule that lists the requested locations, along with a description and summary
of operations/use for each.
XL Catlin Environmental FBO
Application (XLICSE 05/15)
© 2015 XL Insurance Company SE.
All Rights Reserved. May not be copied without permission.
Page 1 of 5
APPLICATION:
Section 1 – APPLICANT INFORMATION
APPLICANT NAME:
Street Address:
City/Province/Postal Code:
Contact Name:
Telephone:
E-mail:
Gross Annual Revenue: $
Number of Employees:
Contact Title:
Fax:
Website:
Section 2 – SITE INFORMATION
a.
Name of Airport where operations are performed:
b.
Address of Airport where operations are performed:
c.
What is the largest aircraft that this Airport can facilitate?
d.
Provide the following information for each runway at this Airport:
Runway Identification Number
e.
Length (km)
Width (km)
Address of hanger(s) leased by the Applicant at the Airport(s) listed in Item 2a. above (if any):
Provide a copy of the executed lease agreement.
Section 3 – OPERATIONS
a.
Check all operations you perform at this location:
Aircraft Refueling,
Aircraft Repairs,
Aircraft Painting,
De-icing
b.
Do you have a cyber security program in place for your operations/facilities?
Yes
No If yes, please attach a copy.
c.
Has a vulnerability assessment been performed on your operations/facilities?
Yes
No If yes, please attach a copy.
d.
Identify who is in charge of your cyber security program.
Section 4 – FUELING VEHICLES
List all fueling vehicles used at this location:
Vehicle Make & Model
XL Catlin Environmental FBO
Application (XLICSE 05/15)
Vehicle ID Number
Capacity
(Litres)
© 2015 XL Insurance Company SE.
All Rights Reserved. May not be copied without permission.
Licensed?
(Yes or No)
Page 2 of 5
Section 5 – FUEL STORAGE TANKS
Aboveground Storage Tanks (ASTs) and Underground Storage Tanks (USTs)
a.
What is your annual throughput of fuel (in Litres)?
b.
Are there any plans to remove any UST within the next 12 months?
If yes, please identify:
Yes
No
c.
Are you responsible for any underground fuel hydrant systems?
If yes, please provide details separately.
Yes
No
d.
For all ASTs, complete the following table:
Tank
Contents
e.
Tank
Contents
f.
Construction
Material
Capacity
(Litres)
Year
Installed
Secondary
Containment
Description
Date of Most
Recent Tank
Tightness Test
Financial
Responsibility
Needed (Y/N)
Description of
Leak Detection
Date of Most
Recent Tank
Tightness Test
Financial
Responsibility
Needed (Y/N)
For all USTs, complete the following table:
Construction
Material
Capacity
(Litres)
Year
Installed
If the UST has continuous interstitial monitoring, when was the last time the monitoring system was
tested?
Section 6 – DE-ICING OPERATIONS
a.
b.
What specific chemicals do you use for de-icing?
Ethylene Glycol,
Diethylene Glycol,
Propylene Glycol,
Other (please specify):
Are de-icing operations performed in a self-contained area?
If yes, please describe:
Yes
No
Yes
No
Section 7 – PAINTING OPERATIONS
a.
Is all painting and/or stripping performed in a self-contained area?
If yes, please describe:
b.
What chemicals and/or processes do you use for stripping paint?
XL Catlin Environmental FBO
Application (XLICSE 05/15)
© 2015 XL Insurance Company SE.
All Rights Reserved. May not be copied without permission.
Page 3 of 5
Section 8 – REPAIR OPERATIONS
a.
Detail what hazardous materials are stored on-site and how they are stored:
b.
Detail what hazardous materials are generated on-site, how they are stored, and how they are disposed
of:
Section 9 – TENANTS
a.
For all tenants of the applicant, complete the following information:
Tenant Name
Describe Tenant Operations
Is Tenant required to carry
environmental insurance per lease?
(Y/N)
Attach an additional sheet, if necessary.
Section 10 – RECORD
a.
Have you ever been investigated, cited and/or prosecuted for contravention or violation of any standard
or law relating to any release of pollutants?
Yes
No
If yes, give details:
b.
Have you ever had any pollution claims including, but not limited to, claims by private persons, entities,
government agencies or other third parties?
Yes
No
If yes, give details:
c.
Are you aware of any past or present contamination on-site or migrating from your site(s), or any
circumstances which may reasonably be expected to give rise to a claim or generate a request for
coverage under this policy?
Yes
No
If yes, give details:
XL Catlin Environmental FBO
Application (XLICSE 05/15)
© 2015 XL Insurance Company SE.
All Rights Reserved. May not be copied without permission.
Page 4 of 5
The proposed insured affirms that the foregoing information is true and agrees that these applications shall
constitute a part of any policy issued whether attached or not and that any willful concealment or
misrepresentation of a material fact or circumstances shall be grounds to rescind the insurance policy.
After reasonable inquiry, I warrant that the information and statements contained in this application for insurance
are true and correct, and that no material facts have been withheld or misstated. I understand that this
application, and all other materials and information submitted to the Company in connection with this application
for insurance, are incorporated and made a part hereof. I also understand that the Company will rely upon the
application, materials and information submitted in the underwriting process in the formation of any subsequent
contract of insurance entered into.
I understand that the completion of this application does not bind coverage. Acceptance of a quotation from the
Company is required prior to binding coverage with the Company.
Applicant’s Signature:
Title:
Print Applicant’s Name:
Date:
Agent/Broker Name:
Print Form
XL Catlin Environmental FBO
Application (XLICSE 05/15)
© 2015 XL Insurance Company SE.
All Rights Reserved. May not be copied without permission.
Page 5 of 5