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Environmental & Pollution Liability Online Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
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Last Name
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Company Owner
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Total number of Principals
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Formal Name of Business
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Year Business Established
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Is this company a subsidiary of another company?
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Business Type
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Street
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City
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State
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ZIP / Postal Code
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Primary Phone Number
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Website Address:
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E-Mail Address
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How many years of experience do you have?
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Have there been any mergers, acquisitions, consolidations or dissolution?
Required
If yes, please explain:
Optional
Number of Employees
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Please provide a breakdown of your staff by job title (e.g. Technician: 1, Engineer: 1, Geologist: 1, Clerical/Admin: 2)
Required
Please specifically describe the nature of your operations with % of revenue derived from each service.
Required
Please select the type(s) of client you have:
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Please provide % breakdown (must add up to 100% for each category above)
Required
Do you perform services in the State of New York?
Required
If “Yes,” what percentage is performed in the five (5) boroughs and what percent in the rest of New York?
Optional
Provide the list of States you operate in, duties in each State and % of all your work performed in that State
Required
Total firm billings for the current 12 month period.
Required
Total firm billings for the prior 12 months.
Required
Does the firm use written contracts on every project?
Required
Does your company use a standard written contract with clients?
Required
If you do not use a standard contract, how are non-standard client agreements reviewed?
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Does your contract contain a limitation of liability and an aribtration clause?
Required
If so, what percentage of contracts contain this clause?
Required
Which of the following does your contract contain?
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Do you use subcontractors?
Required
What percentage of your work is subcontracted to others?
Required
When hiring subcontractors, check off all that apply:
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Are subconsultants and subcontractors hired under a written, standard subcontract?
Required
Does the firm obtain continuing education for professional employees?
Required
Does the firm have in-house quality control procedures?
Required
Does your firm have a written health and safety procedures?
Required
Does your firm have a formal procedures manual?
Required
Do you ever perform operations or services within 50 feet of a railroad?
Required
Does your firm have any aircraft of watercraft exposures?
Required
Does your firm engage in operations involving Exterior Insulation and Finishing Systems? (EIFS)
Required
Do you provide written warranties for your work?
Required
Select all coverages desired:
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Amount of Desired Insurance
Required
Do you currently have insurance?
Required
Prior Insurance
Required
Current Premium
Required
Current Insurance Provider
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Effective Date
Required
/ /
Current Policy End Date
Required
/ /
In the past 5 years, has any claim, suit, or notice of incident been made against your firm, a predecessor firm or an organization for which your firm has assumed liabilities?
Required
In the past 5 years, has any member of your firm or a related entity aware of any circumstances that could result in a claim, suit or notice of incident being brought against them?
Required
Has any entity proposed for insurance closed, sold, merged with or acquired any company in the past 12 months or anticipates doing so in the next 12 months?
Required
Has any Insurer cancelled, restricted or refused to renew your Liability insurance policy in the past 5 years?
Required
Has applicant, or any affiliated, related or predessor entity ever been (or is currently) the subject of bankruptcy, reorganization, solvency, dissolution, or other debtor proceeding, or has it made an assignment for the benefit of creditors?
Required
How did you hear about us?
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Additional Comments
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Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Location
Mailing Address Only
P.O. Box 868
Oakhurst, NJ 07755
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