THIS IS AN APPLICATION FOR EITHER A CLAIMS-MADE OR OCCURRENCE POLICY. PLEASE REVIEW THE APPROPRIATE POLICY CAREFULLY. INSTRUCTIONS: Please print or type clearly. Please answer all questions applicable to the coverages requested. If any questions in those sections do not apply, please answer “N/A.” If additional supporting documentation is needed to answer the questions completely, please reference in the application and attach the additional supporting documentation. The application must be signed and dated by a duly authorized executive, officer, owner, or principal of the applicant. Five (5) years of currently valued loss runs for all requested coverages must be provided if prior coverage exists. IMPORTANT IN ORDER TO GENERATE APPLICATION SPECIFIC TO DESIRED COVERAGES, PLEASE CHECK – COVERAGES REQUESTED AND COMPLETE THE CORRESPONDING SECTION(S) COVERAGE REQUESTED Complete SITE POLLUTION IMPAIRMENT LIABILITY SITE POLLUTION IMPAIRMENT LIABILITY COVERAGE (SPIL) SECTION PACKAGE (SITE POLLUTION AND GENERAL LIABILITY) Complete SPIL Application below and GL Acord COVERAGE Application COMPLETE EXCESS COVERAGE AND PACKAGE EXCESS COVERAGE AND PACKAGE UMBRELLA UMBRELLA SECTION (in addition to primary coverage sections) COVERAGE ENHANCEMENTS Non-Owned Disposal Sites ( NODS) Addendum A – Transportation (TPL) Addendum B – YES Chemical Use, Storage, and Treatment Addendum C Complete applicable COVERAGE ENHANCEMENTS – NO Treatment Facilities Addendum D SECTION (Addendums A F) – – Recycling Facilities, Transfer Stations, or Landfills Addendum D – Above Ground Storage Tanks (AST) - Addendum E GENERAL APPLICANT INFORMATION (MANDATORY) Named insured: Mailing address: Contact name: Telephone #: Fax #: Email address: Company website: Year established: SIC or NAIC Code Acreage EPA ID # (if applicable) Business type: Corporation Individual Joint Venture LLC/LLP Partnership Other FEIN #:
THIS IS AN APPLICATION FOR EITHER A CLAIMS-MADE OR OCCURRENCE POLICY. PLEASE REVIEW THE APPROPRIATE POLICY CAREFULLY. INSTRUCTIONS: Please print or type clearly. Please answer all questions applicable to the coverages requested. If any questions in those sections do not apply, please answer “N/A.” If additional supporting documentation is needed to answer the questions completely, please reference in the application and attach the additional supporting documentation. The application must be signed and dated by a duly authorized executive, officer, owner, or principal of the applicant. Five (5) years of currently valued loss runs for all requested coverages must be provided if prior coverage exists. IMPORTANT – IN ORDER TO GENERATE APPLICATION SPECIFIC TO DESIRED COVERAGES, PLEASE CHECK COVERAGES REQUESTED AND COMPLETE THE CORRESPONDING SECTION(S) COVERAGE REQUESTED SITE POLLUTION IMPAIRMENT LIABILITY COVERAGE (SPIL) Complete SITE POLLUTION IMPAIRMENT LIABILITY SECTION PACKAGE (SITE POLLUTION AND GENERAL LIABILITY) COVERAGE Complete SPIL Application below and GL Acord Application EXCESS COVERAGE AND PACKAGE UMBRELLA COMPLETE EXCESS COVERAGE AND PACKAGE UMBRELLA SECTION (in addition to primary coverage sections) YES NO COVERAGE ENHANCEMENTS Non-Owned Disposal Sites ( NODS) – Addendum A Transportation (TPL) – Addendum B Chemical Use, Storage, and Treatment – Addendum C Treatment Facilities – Addendum D Recycling Facilities, Transfer Stations, or Landfills – Addendum D Above Ground Storage Tanks (AST) - Addendum E Complete applicable COVERAGE ENHANCEMENTS SECTION (Addendums A – F) GENERAL APPLICANT INFORMATION (MANDATORY) Named insured: Mailing address: Contact name: Telephone #: Fax #: Email address: Company website: Year established: SIC or NAIC Code Acreage EPA ID # (if applicable) Business type: Corporation Individual Joint Venture LLC/LLP Partnership Other FEIN #:
Alta_Application_SPL.docx