Contractor's Pollution Liability Questionnaire Page 1 APPLICANT INFORMATION Applicant Name Address City, State, Zip Address City, State, Zip Applicant's Website Year Business Started Physical Address Mailing Address (if different) COVERAGE REQUESTED Proposed Effective Date Limits of Liability $500K/$500K $3MM/$3MM $7MM/$7MM (Per Occur./Aggregate) $500K/$1MM $3MM/$6MM $8MM/$8MM $1MM/$1MM $4MM/$4MM $9MM/$9MM $1MM/$2MM $5MM/$5MM $10MM/$10MM $2MM/$2MM $5MM/$10MM $10MM/$20MM $2MM/$4MM $6MM/$6MM $20MM/$20MM Deductible (circle) $2,500 $5,000 $10,000 $25,000 $50,000 $100,000 Higher Coverage for Mold Yes No If No, Policy Form: Occurrence Claims Made Desire Coverage For All Projects Specific Project SCOPE OF SERVICES If for ALL Projects, describe all contracting services performed and types of projects typically involved in. If for Specific Project, describe the entire project AND the contracting services applicant will perform.
Contractor's Pollution Liability Questionnaire Page 2 PROJECTED ANNUAL SALES FOR EACH CONTRACTING CATEGORY If for Specific Project, enter only the projected revenue of the project; otherwise enter projected annual sales. Projected Annual Sales % Subcontracted Appliance Installation $ % Asbestos or Lead Abatement $ % Barrier or Liner Construction $ % Carpentry or Framing $ % Carpet Cleaning $ % Concrete $ % Construction Management $ % Demolition $ % Dredging $ % Drilling (Environmental) $ % Drilling (Non-Environmental) $ % Drywall $ % Electrical $ % Excavation or Grading $ % Fire Suppression / Sprinklers $ % Flooring $ % General Contracting $ % Glazier/Glass and Window $ % Groundwater Sampling $ % Groundwater Treatment and Recovery $ % Hazardous Material Clean-up $ % Hazardous Waste Treatment $ % Home Building $ % HVAC / Mechanical Refrigeration $ % Insulation (No Abatement) $ % Landscaping $ % Loading and Unloading (Port & Rail) $ % Logging $ % Maintenance and Janitorial $ % Masonry $ % Mobile Incineration $ %
Contractor's Pollution Liability Questionnaire Page 3 Mold Abatement $ % Painting (No Abatement) $ % Paving - Street and Road $ % Pesticide, Herbicide and Fertilizer (No Aerial) $ % Pile Driving $ % Pipeline Construction or Repair $ % Plastering or Stucco $ % Plumbing $ % Recycling (Chemicals or Haz Materials) $ % Recycling (Other) $ % Refinery or Chemical Plants Operators $ % Restoration (Fire and Water Damage) $ % Roofing $ % Sandblasting $ % Sewer and Water Main $ % Soil Remediation $ % Soil Sampling $ % Steel Erection $ % Tanks - AST Installation $ % Tanks - AST Removal $ % Tanks - UST Installation $ % Tanks - UST Removal $ % Waste Storage $ % Waste Water Facility Operators $ % Water Utility Contractors $ % Waterproofing $ % Total Projected Sales: $
Contractor's Pollution Liability Questionnaire Page 4 APPROXIMATE PERCENTAGE OF PROJECTED SALES BY PROPERTY CLASS Single Family Housing % Hotels / Motels % Apartments % Government % Condominiums / Townhouses % Industrial / Manufacturing % Hospitals/Nursing Homes % Retail / Office / Other Commercial % Schools % COMPANY PROFILE Is this a start-up company? Yes No Total Revenue for prior 12-month period: $ Are there any OTHER named insureds to be covered by this policy? Yes No Named Insured Relationship OPERATIONS Specify the estimated percentage of gross receipts in the U.S. attributable to each state: Alabama % Indiana % Nevada % South Dakota % Alaska % Iowa % New Hampshire % Tennessee % Arizona % Kansas % New Jersey % Texas % Arkansas % Kentucky % New Mexico % US Virgin Is. % California % Louisiana % New York % Utah % Colorado % Maine % North Carolina % Vermont % Connecticut % Maryland % North Dakota % Virginia % D.C. % Massachusetts % Ohio % Washington % Delaware % Michigan % Oklahoma % West Virginia % Florida % Minnesota % Oregon % Wisconsin % Georgia % Mississippi % Pennsylvania % Wyoming % Hawaii % Missouri % Puerto Rico % Idaho % Montana % Rhode Island % Illinois % Nebraska % South Carolina % CURRENT GENERAL LIABILITY COVERAGE Carrier Name Expiration Date Current CGL Premium $ Is there a Mold (Microbial Matter) exclusion on the policy? Yes No
Contractor's Pollution Liability Questionnaire Page 5 CURRENT CONTRACTOR'S POLLUTION LIABILITY COVERAGE Does applicant currently have Contractor's Pollution Liability coverage? Yes No Carrier Name Per Occurrence Limit $ / Aggregate Limit $ Expiration Date Deductible $ Retro Date (If Any) Current CPL Premium $ Is there a Mold (Microbial Matter) Exclusion on the policy? Yes No ADDITIONAL DETAILS Is there any additional information you would like the underwriter to consider in reviewing this application? PROJECT INFORMATION (for Project-Specific coverage) Project Owner Project Number Project Street Address / City / State / Zip Project Start Date Estimated Finish Date