EIL - Contractors Pollution Liability Insurance
Environmental impairment liability (EIL) contractors pollution liability (CPL) quote application form.
Broker Information
Broker Name
*
First Name
Last Name
Broker Email Address
*
example@example.com
Broker Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Brokerage Name
Application Information
Company Legal Name
Company Address
Street Address
Street Address Line 2
City
Province
Postal Code
Company website
URL
Company Structure
Limited Company
Joint Venture
Public Corporation
Other
Incorporation Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Has the company previously traded under a different entity/company?
No
Yes
Any additional insureds requesting coverage
Contact Name
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Phone Number
Back
Next
Please describe the 3 largest projects/contracts in the past 12 months
Does any one project represent more than 25% of your annual revenue?
Yes
No
Where are your operations performed?
Canada
United States
Mexico
Central America
South America
Asia
EU
United Kingdom
Middle East
Africa
Australia
Does the prospective Insured have any exposure in countries or regions that are subject to limited or comprehensive sanctions (eg. incorporated, located or domiciled, conducting business activities, generating revenue, board members or majority owned by entities/individuals incorporated, domiciled or located, in such countries)?
Yes
No
If Yes, please provide details
Annual revenue/contract value
Please identify the projected revenue by specific categories and the percentage of subcontracted for each. The sum of contracting operations gross revenues should equal the Estimated Annual Gross Revenues above.
Rows
Projected Gross Revenue ($)
% Subcontracter
Notes/Comments
Asbestos - Residential
Asbestos - Non-Residential
Mould - Residential
Mould - Non-Residential
Abatement / Remediation - Other (Specify) - Residential
Abatement / Remediation - Other (Specify) - Non-Residential
Carpentry / Framing
Demolition / Dismantling
Dredging Activities - Expansion of Waterways
Dredging Activities - Remedial
Drilling - Environmental
Drilling - Oil & Gas
Drilling - Water
Electrical
Emergency Spill Response & Cleanup
General Construction & Management - Environmental
General Construction & Management - Non-Environmental Activities
Groundwater & Soil - Clean Up
Groundwater & Soil - In-situ Treatment
Groundwater & Soil - Sampling
Hauling - Dry Goods
Hauling - Oilfield Fluids
Hauling - Petroleum Residential
Hauling - Petroleum Non-Residential
Hauling - Hazardous Wastes
Hauling - Non-Hazardous Wastes
Hauling - Other (Specify)
HVAC / Mechanical (including Duct Cleaning) - Residential
HVAC / Mechanical (including Duct Cleaning) - Non-Residential
Industrial Cleaning (including Septic / Sewer)
Landfill Construction / Expansion / Capping
Landscaping - Non-Spraying Activities
Landscaping - Spraying Activities
Liner Installation
Logging
Marine Construction or Other Marine Activities
Masonry & Concrete
Painting & Coating
PCB Handling
Pipeline Construction
Plumbing
Railroad Construction
Residential Home Construction
Restoration Contracting
Roofing
Soil Excavation / Grading
Storage Tank Installation / Removal / Maintenance (Aboveground Tanks))
Storage Tank Installation / Removal / Maintenance (Underground Tanks))
Street & Road Construction
Third Party Facility Operation & Maintenance
Other Contracting Activities (Specify)
Existing Insurance Policies - Please provide details of any current pollution liability insurance including the information on Insurer, renewal date,retroactive date, limit of liability and deductible.
Back
Save & Exit
Next
History
Has any the applicant ever had Environmental Liability insurance declined, refused to renew, cancelled or imposed special conditions on your policy or your application at any time?
Yes
No
If Yes, please provide details.
Has the applicant during the past five (5) years had any releases or spills of hazardous substances, hazardous waste or any other pollutants or caused environmental damage, as defined by applicable environmental statutes orregulations?
Yes
No
If Yes, please provide details.
Have you during the last five (5) years been prosecuted, or threatened with prosecution or are you currently being investigated by regulatory authorities in contemplation of prosecution or have you received any penalties, notices orundertakings as defined by environmental laws, statutes or regulations?
Yes
No
If Yes, please provide details.
At the time of the signing of this form, do you know of any facts or circumstances which may reasonably be expected to result in a claim or claims being asserted against your company for environmental clean-up or response, or for bodily injury, property damage or nuisance claims arising from the release of pollutants into the environment or environmental damage?
Yes
No
If Yes, please provide details.
At the time of signing this form, is there any material information, in addition to that disclosed in response to the questions above, which should be disclosed?
Yes
No
If Yes, please state here and/or attach documents and direct the Insurer to the relevant sections.
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Save & Exit
Next
Coverage Options
Preferred options Limit of Liability($):
Preferred options Deductible ($):
Preferred Inception Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Policy Term:
Please indicate if any specific coverages are required:
Please advise status of Copies of Method Statements for the Covered Operations
Enclosed
To Follow
Does Not Exist
Please upload copies of Method Statements for the Covered Operations if "Enclosed" was selected above.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please advise details of Environmental Management Systems and Loss Prevention Measures
Enclosed
To Follow
Does Not Exist
Please upload details of Environmental Management Systems and Loss Prevention Measures if "Enclosed" was selected above.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Save & Exit
Next
DECLARATION
I/we confirm that the information given in this application form and any supplementary information provided is true, accurate and complete. I/we have made a fair presentation of the risk and have disclosed all facts and circumstances which would be material to your acceptance or assessment of the risk in a reasonably clear and accessible manner, whether or not those facts or circumstances were the subject of a specific question in this application form. I/we confirm that I/we have conducted a reasonable search of the information available to me/us (including information held by third parties) in order to reveal those facts and circumstances. If there are any material facts or circumstances not covered by a specific question on this application form, I/we have listed these on a separate sheet of paper which is signed and dated and attached to this application form. I/we understand that if I/we deliberately or recklessly failed to present the risk to you fairly, you may treat this insurance as if it never existed and refuse to make any payment under it. I/we understand that I/we must reimburse all payments already made by you and that you will also be entitled to retain all premiums paid. I/we understand that if I/we failed to present the risk to you fairly but that failure was not deliberate or reckless, the remedy available to you will depend upon what you would have done if I/we had made a fair presentation of the risk. I/we understand that you may treat this insurance as if it never existed and refuse to make any payment under it. I/we must reimburse all payments already made by you. You will refund any premium I/we have paid; or amend the terms and conditions of this insurance and apply those amended terms and conditions from the start of the period of insurance. I/we understand that this may result in a particular claim or loss not being paid. I/we will reimburse you for any payment already made that would not have been paid if such terms had been in effect; and/or reduce the amount of any claim in proportion to the premium that you would have charged if I/we had fairly presented the risk to you. I/we understand that this remedy may apply in addition to those shown in b. above. Please note that the signing of this application form does not bind you to complete or us to accept this insurance.
Signature of Applicant (authorized representative)
Completing Party Name
First Name
Last Name
Completing Party Title / Organization
Confirm Form is Complete
Yes
Save
BOS JotForm Submission Key
BOS JotForm Redirection
Should be Empty: