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

Required

Last Name

Required

Company Owner

Required

Total number of Principals

Required

Formal Name of Business

Required

Year Business Established

Required

Is this company a subsidiary of another company?

Required

Business Type

Required

Street

Required

City

Required

State

Required

ZIP / Postal Code

Required

Primary Phone Number

Required

Website Address:

Required

E-Mail Address

Required

How many years of experience do you have?

Required

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

Required

If yes, please explain:

Optional

Number of Employees

Required

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:

Required

Hold down the Ctrl Key to make multiple selections.

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?

Required

Hold down the Ctrl Key to make multiple selections.

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?

Required

Hold down the Ctrl Key to make multiple selections.

Do you use subcontractors?

Required

What percentage of your work is subcontracted to others?

Required

When hiring subcontractors, check off all that apply:

Required

Hold down the Ctrl Key to make multiple selections.

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:

Required

Hold down the Ctrl Key to make multiple selections.

Amount of Desired Insurance

Required

Do you currently have insurance?

Required

Prior Insurance

Required

Current Premium

Required

Current Insurance Provider

Required

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?

Optional

Additional Comments

Optional

Submission Validation

Required

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