Application date need by date



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APPLICATION DATE NEED BY DATE



CONTRACTOR’S POLLUTION LIABILITY MONOLINE RENEWAL APPLICATION



SECTION A: APPLICANT INFORMATION




APPLICANT





MAILING ADDRESS


CITY


STATE

ZIP CODE





PHYSICAL ADDRESS IF DIFFERENT


CITY


STATE

ZIP CODE








CONTACT NAME

CONTACT E-MAIL




CONTACT PHONE #




WEBSITE ADDRESS








COMPANY IS:  Individual  Corporation  LLC  Partnership  Other (Specify)




PROVIDE BRIEF DESCRIPTION OF APPLICANT’S OPERATIONS:




SECTION B: CURRENT COMMERCIAL GENERAL LIABILITY (CGL) CARRIER INFORMATION




CARRIER

INCEPTION/EXPIRATION DATE

LIMITS OF INSURANCE

DEDUCTIBLE




















SECTION C: GROSS RECEIPTS PAST THREE (3) FISCAL YEARS







FISCAL YEAR

RECEIPTS

Note: Gross Receipts are the total of all receipts, invoices and/or billings without any deductions. Please list your estimated gross receipts including work subcontracted to others for the next 12 months next to the appropriate category. List services not described below under “Other” (be specific).




1st prior year










2nd prior year










3rd prior year








SECTION D: OPERATIONS




  1. Total percent of all work subcontracted to others:




  1. Please list all states where your perform operations:

If you perform any operations in New York State, do you conduct any operations in any of the 5 boroughs of New York City (Manhattan, Brooklyn, Queens, Bronx and Staten Island) and/or Nassau or Suffolk Counties?  Yes  No If yes, what percent?




SECTION E: CLAIMS




  1. Have any claims been made in the past year against the Applicant or reported under any Commercial General Liability or Professional Liability policies?  Yes  No




  1. Has any claim, suit or notice of incident been made against the firm or any staff member?  Yes  No


If yes, please attach full details on each incident.


  1. Is the applicant aware of any circumstances, which may result in any claim, suit or notice of incident against him, the firm, his predecessors in business, any of the present or past partners or officers, or any staff member?  Yes  No


If yes, please attach full details on each incident.




SECTION F: ENVIRONMENTAL CONTRACTING OPERATIONS



Check here if this section does not apply




OPERATIONS

PROJECTED GROSS REVENUE

% SUBBED TO OTHERS

OPERATIONS

PROJECTED GROSS REVENUE

% SUBBED TO OTHERS




Abatement Contracting -Asbestos







Medical/Infectious Waste/Crime Scene Cleanup










Abatement Contracting -

Lead








Mobile Incinerator








Abatement Contracting -

Mold








Mold Prevention










Air Duct Cleaning







PCB Contracting










Alternative Energy Contracting Solar







Radon Mitigation










Alternative Energy Contracting Wind






Recycling - Hazardous Materials











Alternative Energy Contracting Other







Service Station Contracting










Bio Remediation (Soil, Water)







Sewage Waste Remediation










Build Back/Restoration







Soil Remediation (Petroleum)










Debris Removal (Hazardous Materials)





Soil Remediation (Other)










Debris Removal (Non Hazardous/Waste)







Soil Removal










Drilling







Tank and Pipe Cleaning










Emergency/Spill Response – Fire (No Build Back)







Tank - AST Contracting









Emergency/Spill Response (Rolling Stock/Vessel Spill)








Tank - UST Installation Contracting










Fire & Water Damage Restoration Work







Tank - UST Removal Contracting










Fuel System Installation







Trucking – Hazardous Materials










Groundwater Remediation







Waste Contracting – Hazardous Materials








Illegal Drug Lab Cleanup







Waste Contracting – Non-Hazardous Materials










Indoor Air Quality







Waste Water Facility Operators










Industrial Cleaning







Water Extraction










Lab Packing

and Sampling









Wetlands Restoration and Construction









Landfill Construction







Other (Specify)










Liner Installation







Other (Specify)










Liquid Waste Management and Treatment







TOTALS FOR ENV CONTRACTING










SECTION G: NON-ENVIRONMENTAL CONTRACTING OPERATIONS




Check here if this section does not apply










OPERATIONS

PROJECTED GROSS REVENUE

% SUBBED

TO OTHERS

OPERATIONS

PROJECTED GROSS REVENUE

% SUBBED TO OTHERS




Appliance Installation







Drilling – Water










Boiler Inspections

and Installations









Driveway, Parking Area or Sidewalk Paving or Repaving









Bridge or Elevated Highway Construction – Concrete Water)








Drywall or Wall Installation










Bridge or Elevated Highway Construction – Iron or Steel (Over Water)







EIFS










Carpentry







Electrical Contracting










Carpet, Rug, Furniture or Upholstery Cleaning







Equipment Sales

UST – Fueling










Concrete Construction – Foundation Work







Excavation










Dredging







Exterior Demolition of 4 Story Building











OPERATIONS

PROJECTED GROSS REVENUE

% SUBBED

TO OTHERS

OPERATIONS

PROJECTED GROSS REVENUE

% SUBBED TO OTHERS




Fencing





Painting










Fire Suppression Systems – Installation, Servicing /Repair







Pile Driving Building Foundation Only










Floor Covering Installation – Not Ceramic or Stone Tiles







Pile Driving – Sonic Method










Floor Covering Mfg Not Carpets, Rugs







Plastering or Stucco Work (No EIFS)








Framing








Plumbing










Furniture Moving







Pressure Washing










Gas Mains or Connections







Refrigeration Systems or Equipment – Dealers










General Contracting – Commercial & Residential






Rigging – Not ship or Boat











Glass Dealers & Glaziers (3 stories or less)







Roofing










Glass Dealers & Glaziers (more than 3 stories)







Salvage Operations










Grading of Land







Sewer Mains or Connections Construction










HVAC





Street Cleaning











Industrial Cleaning, Maintenance







Street or Road Construction or Reconstruction










Insulation Work – Mineral







Street or Road Paving or Repaving, Surfacing










Insulation Work – Plastic







Trucking









Insulation Work – Organic or Plastic in Solid State








Water Mains or Connections Construction










Interior Demolition/by Hand (more than 6 stories)







Waterproofing










Interior Demolition/by – not more than 6 stories







Welding or Cutting (No Oil/Gas Pipeline)










Janitorial Contents Cleaning







Wrecking – Buildings No Explosives, Wrecking Balls










Machinery or Equipment – Installation, Service Repair







Wrecking – Exterior Demolition of 1 & 2 Story










Masonry Contracting (No EIFS)







Other (Specify)










Metal Erection Contracting – Decorative or Artistic







Other (Specify)










Metal Erection – Non Structural






Other (Specify)










Metal Erection – Structural







Other (Specify)










Millwright/Welders







TOTALS FOR NON-ENVIRONMENTAL














FRAUD WARNING: APPLICABLE TO ALL STATES

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

WARRANTY STATEMENT

The undersigned authorized officer of the applicant declares that the statements set forth herein are true. The undersigned authorized officer agrees that if the information supplied on the application changes between the date of the application and the effective date of the insurance, he/she (undersigned) will immediately notify the insurer of such changes, and the insurer may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. Signing of this application does not bind the applicant or the insurer to complete the insurance.





NOTICE TO APPLICANTS:

Any person who knowingly and with intent to defraud any insurance company or Other person files an application for insurance containing any false information, or conceals for the Purpose of misleading, information concerning fact material thereto, commits a fraudulent insurance Act, which is a crime.


You agree that if the information supplied in the Application changes between the date of this Application and the effective date of the proposed insurance, then you will immediately notify the Underwriters of such changes.


Signature: Date:




Title:







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