Energy Insurance Mutual Limited Excess General Liability Insurance Renewal Application

Transcription

1 Energy Insurance Mutual Limited Excess General Liability Insurance Renewal Application THE COMPLETION AND SUBMISSION TO ENERGY INSURANCE MUTUAL LIMITED OF THIS APPLICATION FOR THE RENEWAL OF EXCESS GENERAL LIABILITY INSURANCE DOES NOT CONSTITUTE A BINDING CONTRACT OF INSURANCE NOR ANY INSURANCE COVERAGE WHATSOEVER, NOR DOES IT COMMIT ENERGY INSURANCE MUTUAL LIMITED TO OFFER OR THE APPLICANT TO PURCHASE ANY COVERAGE. THIS APPLICATION IS FOR THE RENEWAL OF AN EXCESS GENERAL LIABILITY CLAIMS FIRST MADE INSURANCE POLICY. THE POLICY PROVIDES COVERAGE WHICH IS DIFFERENT FROM THAT PROVIDED BY OTHER POLICIES. THE POLICY ALSO PROVIDES FOR ALTERNATE DISPUTE RESOLUTION FOLLOWED, IF NECESSARY, BY MANDATORY ARBITRATION OF ALL DISPUTES WHICH MAY ARISE UNDER THE POLICY. AS PART OF THIS APPLICATION, IT IS NECESSARY TO ATTACH THE ITEMS LISTED ON PAGE 4 SECTION 6, WHICH SHALL BE INCORPORATED INTO AND CONSTITUTE A PART OF THIS APPLICATION: Please Return To: Energy Insurance Mutual Limited 3000 Bayport Drive, Suite 550 Tampa, Florida Applicant Company Name: 2. (a) Contact Person Name: Phone Number: Fax Number: Address: EGL RENEWAL APP - REV. 01/2012 PAGE 1 OF 5

2 2. (b) Person Authorized to accept Service of Process Name: 3. Insurance Proposals Requested Please state limits to be quoted if different from current limits. Note: Minimum attachment point is $35 million. Option 1 Option 2 Option 3 4. Applicant Information Please note any changes that have occurred since the last full EIM application was completed. If Yes, is checked, please attach an explanation detailing the changes. (a) Gas Utility Operations Yes No Gas/Oil Exploration On Shore Yes No Drilling On Shore Yes No Well Operations On Shore Yes No Gathering System Yes No Gas Fractionation Yes No Gas Extraction Yes No Transmission Yes No Distribution Yes No Manufactured Gas Plants Yes No Synthetic Gas Plants Yes No Storage Facilities Above Ground Yes No Under Ground Yes No LNG Storage for others Yes No LPG Storage for others Yes No EGL RENEWAL APP - REV. 01/2012 PAGE 2 OF 5

3 4. Applicant Information (continued) (b) Mining Deep Yes No (c) Other utility operations Surface Yes No Water Operations Yes No Telecommunication Operations Yes No (d) Dams Yes No (e) Cogeneration/Independent Power Producer Yes No (f) Joint Ventures Yes No (g) Construction Operations Yes No If Yes, on an attached sheet, please describe all construction projects with an estimated cost of $100,000,000 or more. (h) Foreign Operations Yes No If Yes, on an attached sheet, please describe. (i) Property in Care, Custody and Control Yes No If Yes, on an attached sheet, please describe all items exceeding $5,000,000 in value. (j) Discontinued Operations Yes No (k) Watercraft Operations Yes No (l) Aircraft Operations Yes No (m) Any other operations Yes No 5. Claims Experience Please attach updated information for each claim, paid or outstanding, insured or not, which exceeds $1,000,000 including defense costs, giving the amount paid or outstanding of each claim. EGL RENEWAL APP - REV. 01/2012 PAGE 3 OF 5

4 6. Required Attachments Please attach to submission or provide the website link for each document. a) Copy of underlying application (please include all attachments and loss runs for a minimum of five years) b) Applicant s latest 10-K and all 10-Q and 8-K reports subsequently filed with the Securities and Exchange Commission if publicly traded c) List of subsidiaries for which coverage is requested d) Copy of all dam inspection reports required by regulatory authorities (summary findings only) e) Copy of limitation of liability section of rate tariff issued by applicable regulatory agencies for each state there Applicant operates. f) Copy of standard insurance and hold harmless provisions incorporated into any contract for services (if changed) g) Gas pipeline questionnaire (if applicable) h) Copies of PHMSA 7100 reports for gas transmission and gas distribution (if applicable) i) Copy of vegetation mgmt. / tree trimming program (for electric transmission / distribution only) j) Copy of pipeline integrity management program (if applicable) EGL RENEWAL APP - REV. 01/2012 PAGE 4 OF 5

5 7. Renewal Representations and Warranties IT IS AGREED THAT THIS RENEWAL APPLICATION AND ANY UNDERLYING APPLICATION CONSTITUTE THE COMPLETE APPLICATION WHICH WILL BE THE BASIS OF THE POLICY AND WILL BE ATTACHED TO AND BECOME A PART OF THE POLICY. UNDERLYING APPLICATION SHALL MEAN ANY APPLICATION SUBMITTED IN CONJUNTION WITH THIS APPLICATION. THE APPLICANT, BASED ON REASONABLE INQUIRY, WARRANTS AND REPRESENTS TO THE BEST OF ITS KNOWLEDGE AND BELIEF THAT: (a) the statements set forth herein and in the Underlying Application are true and that applicant knows of no other relevant facts that might affect the judgment of Energy Insurance Mutual Limited when considering this application; and (b) by signing this application, the applicant acknowledges that he has reviewed the mandatory Governing Law and Interpretation and Dispute Resolution provisions contained in the current Policy provisions and agrees to be bound by such mandatory provisions should a renewal policy be issued; and (c) that if the information supplied in this application, including attachments hereto, changes or publicly available documents deemed to be part of this application changes materially between the date of this application and the inception date of the Policy Period, the Applicant will immediately notify Energy Insurance Mutual Limited and Energy Insurance Mutual Limited may withdraw or modify any outstanding quotations or agreements to bind coverage. Signature: Company: Date: EGL RENEWAL APP - REV. 01/2012 PAGE 5 OF 5