Combined General Liability and Site Pollution Liability Renewal Appplication

General Liability and Site Pollution Liability Renewal Application

• This Renewal Application applies only to locations currently scheduled on the existing policy.
• For any new locations to be added to the policy submit a completed original application for those locations.
• Please print or type clearly. • Answer all questions completely. If any question(s) does not apply, print or type “N/A” in the space provided.
• This application must be signed and dated by an authorized Owner, Principal, Partner, Director or Risk Manager of the Named Insured. • If additional space is needed to answer any question, attach details on a separate sheet and reference the applicable question number.
• Please attach an ACORD GL Application

Insured Information

Business Name

Applicant Address

Mailing Address City State / Province / Region ZIP / Postal Code Country

Name of Contact

Title

Telephone

Federal Employee Identification Number (FEIN)

EXPIRING POLICY INFORMATION

Policy Number:

Policy Expiration Date

COVERED LOCATION INFORMATION: (Attach additional pages if necessary)

For EACH location scheduled on the current policy, please answer the following:

a. Do you reaffirm the information provided on the original application for insurance and any previous renewal applications, if applicable, other than amended herein?

Yes

b. Are you aware of any circumstances which may reasonably be expected to give rise to a claim for bodily injury, property damage or cleanup costs or generate a request for coverage under this policy? If yes, please provide details:

Yes

Circumstances expected to give rise to a claim:

c. Have there been any changes in use or changes in operations at the covered location during the policy period? If yes, please provide details:

Yes

Changes In Use or Operation Details

d. Are there any plans for future development, improvement, excavation, betterment, demolition or plans for changes in use? If yes, please provide details:

Yes

Plans for Future Development Details

e. Have there been any releases or spills of hazardous substances, hazardous wastes, or any other pollutants during the policy period? If yes, please provide details and attach copies of applicable reports.

Yes

Releases or Spills Details:

f. During the policy period, have you been cited or prosecuted for any violation of any applicable environmental law and/or federal, state or local regulation arising from the release or spill of hazardous substances, hazardous waste or any other pollutants? If yes, please provide details:

Yes

Citation or Violation Additional Details:

g. Are there any statutes, standards, or other city, state and/or federal regulations relating to the protection of the environment with which you cannot at the present comply with? If yes, please provide details:

Yes

Cannot Comply Details:

h. During the policy period, have there been any pollution claims for bodily injury, property damage or cleanup costs including, but not limited to, claims by private persons, public entities, governmental agencies or other third parties not reported to the Company? If yes, please provide details and attach copies of applicable reports.

Yes

Pollution Claim Details:

i. Are you aware of any waste materials that have been disposed of or buried on the covered location during the policy period? If yes, please provide details:

Yes

Waste Materials Details:

j. During the policy period, have there been any water intrusion, indoor air quality and/or mold problems; visible signs of mold growth; complaints by a third party relating to indoor air quality and/or mold problems; or inspections conducted regarding the same? If yes to any part, please provide details and attach copies of applicable reports

Yes

Water Intrusion Details

Water Intrusion Files

Drop files here or

Max. file size: 50 MB, Max. files: 5.

k. Are there any future plans to sell or sublease the covered location within the next three (3) years? If yes, please provide details:

Yes

Future Plans Details:

l. Have there been any changes in the products sold during the policy period? If yes, please provide details

Yes

Changes in Product Details:

CYBER EXPOSURES

Cyber Exposures Checkbox

Check here if this section does not apply

Limits Requested

Aggregate Sublimit(s) of Insurance	Aggregate Limit of Insurance
$10,000	$25,000
$25,000	$50,000
$50,000	$100,000
$100,000	$200,000
$250,000	$500,000
$500,000	$1,000,000

Annual revenue generated from or attributable to activities conducted on your web site(s) (If Applicable):

Summary of E-Commerce Activities Conducted Via Your Web Site(s):

Encryption

a) Does your organization encrypt all e-mails containing sensitive information (e.g., Personally Identifiable Information [PII], Personal Health Information [PHI], Payment Card Information [PCI]) sent to external parties?

Yes

b) Does your organization encrypt all sensitive information (e.g., PII, PHI, PCI) Stored on mobile devices (e.g., phones, tablets, wearable computers, flash drives)?

Yes

Information Security Leadership

Does your organization have an individual officially designated for overseeing Information security?

Yes

Cloud

Does your organization have sensitive information (e.g., PII, PHI, PCI) stored on the cloud (e.g., Carbonite, Google Drive, Dropbox)? If so, which provider(s) is used?:

Yes

Cloud Storage

Employee Management

Does your organization provide mandatory information security training to all employees at least annually?

Yes

Are your information security personnel provided with additional training to help them understand current security threats?

Yes

Additonal Security Info Details:

CYBER INSURANCE COVERAGE HISTORY

1. List prior cyber/security privacy insurance for past three years, including both stand-alone policies and supplemental coverage provided under some other type of insurance.

Insurance Company

Insurance Limits

Deductible/Retention

Policy Period

Premium

2. Has any cyber/security privacy insurance policy listed above been canceled?

Yes

3. What is the Retroactive Date of your Cyber Insurance Policy currently in effect? If you do not have a Cyber Insurance Policy currently in effect, please answer N/A.

What is the Retroactive Date of the following Insuring Agreements?

a) Security Agreement

b) Extortion Threats

c) Replacement or Restoration of Electronic Data

d) Business Income and Extra Expense

f) Security Breach Liability

e) Public Relations Expense

During the last three years has your organization suffered a security breach requiring Customer or third-party notification according to state or federal regulations?If Yes, please describe both the cause of the security breach and the economic loss to your organization:

Yes

Cause & Economic Loss

If Yes, how did your organization respond to the security breach?

VEHICLE EXPOSURES

Number of drivers

Number of company owned vehicles (list below)

Private Pass:

Light Trucks:

Medium Trucks

Heavy Trucks:

Heavy Truck Tractors:

Extra-Heavy Trucks:

Extra-Heavy Truck Tractors:

Trailers:

Do you have a written procedure for the screening and hiring of drivers? If yes, please provide details:

Yes

Written Procedure:

Are MVR’s pulled on all drivers? If yes, please provide details:

Yes

MVR Details:

As part of a formal driver qualification program are MVR’s reviewed using set criteria at least annually by the insured? If MVR’s are reviewed but not by the insured, please identify who reviews them:

Yes

Reviewer:

Do employees use personal vehicles in business? If yes, list percentage of employees who use their own vehicles:

Yes

Percentage Who use Own Vehicles:

Do you use owner/operators? If yes, please describe:

Yes

Owner/Operator Details:

Do you allow employees to take company vehicles home?

Yes

Are they allowed to drive the vehicles during non-work hours?

Yes

Do you have a written policy regarding the use of cell phones while operating vehicles?

Yes

Cell Phone Policy:

EMPLOYEE JOBSITE EXPOSURES

Number of employees

Employee turnover rate (%)

Please enter a number from 0 to 100.

Percent union employees (%)

Please enter a number from 0 to 100.

Percent non-union employees (%)

Please enter a number from 0 to 100.

Do you use temporary employees?

Yes

Temporary Employee Details:

Is job training provided?

Yes

Job Training Details:

Do you obtain a written employment application?

Yes

Do you obtain pre/post-employment physicals? If yes, which one (pre or post-employment)?

Yes

Physicals Details:

Do you perform drug/substance abuse tests?

Yes

If yes, for all employees or just CDL drivers?

If yes, indicate what testing is done: pre-hire, post-accident, random and/or for-cause?

Do you use a specific medical provider to treat injured employees? If yes, please provide details:

Yes

Please provide details:

Do you have a full time Safety Director? If yes, please provide their name:

Yes

Please provide their name:

Do you have a written safety program? If yes, please provide copy of table of contents.

Yes

Safety Program Table of Contents:

If you have a written safety program does it include a positive incentive program? If yes, please provide details:

Yes

Positive Incentive Program Details:

Are safety/tailgate meetings conducted? If yes, how often?

Yes

Frequency of Safety Meetings

Do you have a written fall protection program? If yes, indicate at what height 100% fall protection is required:

Yes

100% Fall Protection Height

Is any work performed above 2 stories?

Yes

Do you perform roof work?

Yes

Do you use scaffolds?

Yes

Do you perform any confined space work? If yes, please provide details?

Yes

Confined Space Details

Do you have a lock-out/tag-out program? If yes, please provide details?

Yes

Lock-Out/Tag-Out Details:

Do you have a hazardous materials communication program? If yes, please provide details?

Yes

Hazardous Material Communication Details:

Do you have a formal equipment inspection/maintenance program? If yes, please provide details?

Yes

Formal Equipment Inspection Details:

Do you have set procedures for reporting a claim? If yes, please provide details?

Yes

Claim Report Procedure:

Is there a formal accident investigation report? If yes, please provide details?

Yes

Formal Accident Investigation Details:

Is modified duty offered to injured employees?

Yes

Do you have a Return To Work program?

Yes

Note to Applicant

The applicant represents that the above statements and facts are true and that no material facts have been suppressed or misstated. Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy issuance. The coverage applied for is solely as stated in the policy and any endorsement thereto, which provides coverage for cleanup costs, bodily injury and property damage liability coverage for claims first made against the insured and reported to the insurer, in writing, during the policy period. 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. The applicant further acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation.

Applicant Signature

Printed Name

Title

Date

Agent/Broker Firm

Broker Address

Fraud Warning

NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO CALIFORNIA APPLICANTS: For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING - It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NOTICE TO NEW MEXICO: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NOTICE TO NEW YORK 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 insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS: WARNING Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO PENNSYLVANIA 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 insurance act, which is a crime and subjects such person to criminal and civil penalties.

NOTICE TO RHODE ISLAND: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.

NOTICE TO ALL OTHER STATE 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, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.

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Combined General Liability and Site Pollution Liability Renewal Appplication

General Liability and Site Pollution Liability Renewal Application

Insured Information

EXPIRING POLICY INFORMATION

CYBER EXPOSURES

VEHICLE EXPOSURES

Note to Applicant

Fraud Warning

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