EIL - Premises Pollution Liability Insurance
Environmental impairment liability (EIL) premises pollution liability (PPL) 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
Primary Contact Name
*
First Name
Last Name
Primary Contact Email
*
example@example.com
Contact Phone Number
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Profile of Operations
Please describe the Business Activities undertaken for which coverage is required:
What percentage of the business is performed on third-party sites (i.e installation work)?
%
How long have you been in business performing these activities?
Insured Locations: Please list the total number of properties to be covered under this policy
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/Rental Income:
Rows
Annual Revenue ($)
Annual Rental Income ($)
Previous Year
Current Year
Next Year (Projected)
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Storage Tanks
Are you are seeking coverage for pollutants emanating from storage tanks? Please Note: All tanks requiring coverage must be located at an Insured Location.
Yes
No
Above ground Storage Tanks (AST) Complete form and select [+ Add Another Aboveground Storage Tank] to add additional tanks.
Underground Storage Tanks (UST) Complete form and select [+ Add Another Underground Storage Tank] to add additional tanks.
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History
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.
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
Do you have a formal environmental management system which conforms to ISO 14001 applicable to all sites?
Do you have a plan in place to respond to any spills or leaks?
Are there groundwater monitoring wells located at any of the Insured Locations?
Have there been any reportable spills of regulated substances, hazardous waste or other pollutants at any of the Insured locations?
Has the applicant received any fines, penalties, notice of violations, complaints or enforcement actions regarding compliance in the last 5 years?
Yes
No
If Yes, please provide details.
At the time of signing this application form, are you aware of any facts or circumstances which could reasonable be expected to give rise or result in a claim or order against them?
Yes
No
If Yes, please provide details.
List all the claims made against you during the last 5 years, for clean-up costs, bodily injury, property damage, orenvironmental damage resulting from the release of hazardous substances or pollutants
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Coverage Options
Preferred Limit of Liability ($):
Preferred Deductible ($):
Preferred inception date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Preferred Policy Period
Please indicate if any specific coverages are required:
Please provide 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.
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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 proposal 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
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