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 *

Last Name *

Company Owner *

Total number of Principals *

Formal Name of Business *

Year Business Established *

Is this company a subsidiary of another company? *

Business Type *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

Website Address: *

E-Mail Address *

How many years of experience do you have? *

Have there been any mergers, acquisitions, consolidations or dissolution? *

If yes, please explain:

Number of Employees *

Please provide a breakdown of your staff by job title (e.g. Technician: 1, Engineer: 1, Geologist: 1, Clerical/Admin: 2) *

Please specifically describe the nature of your operations with % of revenue derived from each service. *

Please select the type(s) of client you have: *

Hold down the Ctrl Key to make multiple selections.

Please provide % breakdown (must add up to 100% for each category above) *

Do you perform services in the State of New York? *

If “Yes,” what percentage is performed in the five (5) boroughs and what percent in the rest of New York?

Provide the list of States you operate in, duties in each State and % of all your work performed in that State *

Total firm billings for the current 12 month period. *

Total firm billings for the prior 12 months. *

Does the firm use written contracts on every project? *

Does your company use a standard written contract with clients? *

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? *

If so, what percentage of contracts contain this clause? *

Which of the following does your contract contain? *

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Do you use subcontractors? *

What percentage of your work is subcontracted to others? *

When hiring subcontractors, check off all that apply: *

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Are subconsultants and subcontractors hired under a written, standard subcontract? *

Does the firm obtain continuing education for professional employees? *

Does the firm have in-house quality control procedures? *

Does your firm have a written health and safety procedures? *

Does your firm have a formal procedures manual? *

Do you ever perform operations or services within 50 feet of a railroad? *

Does your firm have any aircraft of watercraft exposures? *

Does your firm engage in operations involving Exterior Insulation and Finishing Systems? (EIFS) *

Do you provide written warranties for your work? *

Select all coverages desired: *

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Amount of Desired Insurance *

Do you currently have insurance? *

Prior Insurance *

Current Premium *

Current Insurance Provider *

Effective Date *

Current Policy End Date *

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? *

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? *

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? *

Has any Insurer cancelled, restricted or refused to renew your Liability insurance policy in the past 5 years? *

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? *

How did you hear about us?

Additional Comments

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.

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Location

Mailing Address Only
P.O. Box 868
Oakhurst, NJ 07755