Application for Septic Hauler

Contractors Pollution Liability

LIU Environmental

INSTRUCTIONS

  • Please answer all questions. If any section does not apply, please indicate with N/A.

If more space is needed, please attach additional pages.

  • This application must be signed and dated by an owner, principal or other duly authorized representative of the applicant.
  • Please submit the following with this application:

Currently valued General Liability and/or Contractor’s Pollution liability loss runs for the past five years

Brochures/Statement of Qualifications

1.Named Insured & Address
Street & P.O. Box):
2.Contact Name, Telephone Number & Web Site Address:
3.What Policy is being requested: / Claims Made:Retroactive date: Occurrence:
4.What Limits and Deductible are you requesting: / Limits: Each Incident / Policy Aggregate
Retention Each Incident
5.Total Gross Revenue: / Fiscal Year is from: to
Previous Fiscal Year:$
Current Fiscal Year:$
Estimated for next Fiscal Year:$
6.Number of Personnel: / Principals/Owners:
Other (please describe):

7.Services

/ % of Projected Revenue / % Sub Contracted
Septic - System Design / % / %
Septic - Installation / % / %
Septic Pumping/Disposal / % / %
Septic Cleaning / % / %
Septic Closure / % / %
Excavation and Grading Services / % / %
Remedial Action Contracting Services / % / %
Underground Storage Tank Installation and Removal Services / % / %
Other (Please Specify) / % / %
Other (Please Specify) / % / %
Total / % / %

8.What percentage of your operations are: Residential: % Commercial: % Industrial: %

9.Transportation:

a. What is the total Number of vehicles hauling septic waste?

b. What is the average mileage per trip when hauling septic waste?

c. Do you have an Auto Safety, Driver Training and Driver Selection Program in place? Yes No

d. Has the Named Insured had Pollution Claims from transported cargo in the past 5 years? Yes No

If yes, please explain:

10.Are you in compliance with federal and provincial regulations regarding collection, treatment,temporary storage, and disposal of septic waste?
If No, please explain: / Yes No
Describe treatment, storage and disposal facilities utilized:

11.What professional licenses, certifications/training certifications or registrations do you hold?

12.Do you have SOP’s regarding septic system exposures (e.g. identification, abatement, control)? Yes No

13.Do you obtain Certificates of Insurance from your subcontractors? Yes No

14.Has any application for Contractor’s Pollution Liability Insurance by the applicant, present owners, principals or partners ever been declined or coverage cancelled or non-renewed? If yes, please explain: / Yes No
15.Has any claim, suit, or demand for money or services ever been made against the applicant, its subsidiaries, or its principals? / Yes No If yes, please explain including the following details:
a. Date of claim, suit, notice or request was made:
b. Date of incident resulting in claim, suit, notice or request:
c. Name of Claimant:
d. Nature of claim, suit, notice or request:
e.Amount of demand:
f.Amount paid or estimation of payment including reserves:
  1. Current status or final disposition:

16.Is the applicant aware of the following: any circumstances or any allegations of the applicant’s liability, or any allegations of an act, error, or omission in the performance of the applicant’s services which may result in any claim, suit, or demand for money or services against the applicant or any person or entity for who, the coverage is sought? If yes, please explain: / Yes No

PLEASE NOTE THAT THE POLICY SHALL NOT APPLY TO SUCH REPORTED CLAIMS OR CIRCUMSTANCES, UNLESS SCHEDULED ONTO THE POLICY BY ENDORSEMENT.

Completion of this form does not bind coverage. Applicant’s acceptance of company’s quotation and company’s written agreement to be bound are required to bind coverage and issue policy.

NOTICE TO APPLICANTS: 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 act, which is a crime and may subject such person to criminal and civil penalties.

The applicant represents that the above statements and facts are true and that no material facts have been suppressed or misstated. All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this application and made a part hereof. If an order to bind is received, the application is attached to the policy, so it is necessary that all questions be answered in detail.

Applicant signature: / Date:
Name and title (print):
Broker name and firm: / Contact:
Broker address: / Telephone:
Email:

Septic Hauler Application 08.101 of 3