EnviroPro / Pollution Legal Liability Proposal Form

Transcription

1 Instructions Please complete all questions in this Proposal Form. Please provide the following documents and materials along with the completed original signed and dated application: Any Environmental Surveys/Audits conducted at the location within the past five (5) years. Enclosed Information to follow Do not exist If more space is needed to answer any of the questions below, please attach additional page(s) to this application. If multiple properties are being considered, please include answers for each location. Applicant s Details Name of Insured Address of Insured line one Address of Insured line two City and postcode Website List subsidiary companies requesting coverage Named insured is a Partnership Corporation Joint venture Other Business description Provide the addresses of the location(s) to be covered including a brief summary description of activities conducted at each location (e.g. primary manufacturing, warehouse, onsite waste water treatment) Describe specifically any locations which are inactive or closed landfills or surface impoundments Prior property uses Is a change in use or any capital improvement at any of the properties anticipated during the Policy Term? Yes No If Yes, please describe

2 Are there or were there any underground storage tanks located on the property(s)? Yes No If Yes, please complete Appendix A Describe fully the properties immediately adjacent to the property(s) Is any remediation or cleanup currently ongoing or planned? If so, has the remediation plan been approved and accepted by a regulatory body? Yes No If Yes, please describe NOTE: For the purposes of Questions (a) to (d). YOU includes the Corporation, Entity, or Partnership of the applicant and any Director, Officer or Partner thereof. (a) Have you during the past five (5) years had any reportable releases or spills of hazardous substances, hazardous waste or any other pollutants or caused environmental damage, as defined by applicable environmental statutes or regulations?. Yes No (b) Have you during the last five (5) years been prosecuted, or threatened with prosecution or are you currently being prosecuted, or have you received any penalties, notices or undertakings under the Environmental Civil Sanctions Order 2010, for any offence directly or indirectly arising out of a release from the Insured Property(s) of any substance into sewers, rivers, sea, air or onto land or groundwater; or environmental damage (i.e. damage to land, water or biodiversity)? Yes No (c) List all claims made against you during the past five years for cleanup or bodily injury, or property damage, resulting from the release of hazardous substances, hazardous waste or other pollutants or environmental damage, from the location(s) owned or operated by you, into the environment. Provide a brief description of the claim(s) and its disposition. 2 of 5

3 None to report. (d) At the time of the signing of this application, 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 cleanup or response, or for bodily injury or property damage arising from the release of pollutants into the environment or environmental damage? Yes No Last Year Estimated Current Year Turnover Declaration The Applicant represents that the above statements and facts are true and that no material facts have been suppressed or misstated. Completion of this form does not bind coverage and further underwriting information may be required. Applicant s acceptance of Insurer s quotation and Insurer s written agreement to be bound is required to bind coverage and to issue policy. It is agreed that this form shall be the basis of the contract should a policy be issued, and will be attached to the policy. All written statements and materials furnished to the Insurer in conjunction with this application are hereby incorporated by reference into this application and made a part hereof. If an order is received, the application is attached to the policy so it is necessary that all questions be answered in detail. Signed Title (to be signed by a director of the Company) Company AIG Europe Limited The AIG Building 58 Fenchurch Street London EC3M 4AB Tel: Fax: of 5

4 Appendix A Storage Proposal Form Ref Site Above Ground (AST) or Below Ground (UST) Installed Capacity of tank contents construction detail Overfill / spill / secondary containment protection leak detection Wet Stock Management System How often is the WSM reviewed How often are the pumps etc serviced and result of last integrity test of next integrity test Pipework construction details and leak detection 4 of 5

5 American International Group, Inc. (AIG) is a leading international insurance organisation serving customers in more than 130 countries and jurisdictions. AIG is the marketing name for the worldwide property-casualty, life and retirement, and general insurance operations of American International Group, Inc. This material is for information purposes. Products and services are written or provided by subsidiaries or affiliates of American International Group, Inc. and may not be available in every jurisdiction. For additional information, please visit our website at Registered in England: company number Registered address: The AIG Building, 58 Fenchurch Street, London EC3M 4AB AIG Europe Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and Prudential Regulation Authority. UC EIL OCT14