Step Two: Please
print the forms below by clicking "print "
in your browser. Complete and fax the forms to (800) 999-3987.
You will receive a FREE, no obligation quote, within 2 business days.
Remediation "Cost Cap" Quote
To receive this quote
you will need to complete both of the following forms.
Please contact Bill Lohman at
(800) 992-6999 if you need any assistance
in completing these forms.
| BROKER NAME | APPLICANT NAME | ||
| PROPOSED EFFECTIVE DATE / / | EXPIRATION DATE / / | ||
| DEDUCTIBLE DESIRED | LIMITS OF LIABILITY REQUESTED | ||
$10,000 $25,000 $50,000 |
$1,000,000 per occurrence / $1,000,000 policy limit aggregate |
||
| GENERAL INFORMATION - Explain all "YES" responses | |||
Yes/No / Dose applicant have a written environmental/
|
Yes/No / Has Applicant, or any affiliate, related or |
||
| Describe the sampling and monitoring procedures in and around the contaminated property. | |||
| What types of environmental remediation services will be required and what is the estimated contact amount for each? | |||
| Asbestos Abatement | $ |
Emergency Response |
$ |
| Lead Abatement | $ | Microbiological Decontamination | $ |
| Soil Remediation | Duct Cleaning | $ | |
| Bioremediation | $ | Medical Waste Remediation | $ |
| Vapor Extraction | $ | Groundwater Remediation | $ |
| Incineration | $ | Superfund / Landfill (describe) | $ |
| Dig & Haul | $ | ||
| Other | $ | Waste Incineration (describe) | $ |
| ABOVE/UNDERGROUND STORAGE TANKS: | |||
| Removal | $ | Building Decontamination | $ |
| Installation | $ | (Other than asbestos or lead) | |
| Cleaning | $ | Other (describe) | $ |
|
Please describe clearance/closure standard required by the local regulatory agency for each remediation activity described above |
|||
| SUPPLEMENTAL INFORMATION - Required from all Applicants | |||
| Attach each item listed to Application | |||
|
Providing
a list of all contractors to be utilized or proposed to be utilized for remediation activities of the contaminated property site. |
Attach proposed contractors'/subcontractors' qualification statement to this application. |
||
|
Provide a list of all subcontractors preforming
environmental remediation work. |
Provide a copy of all environmental surveys/audits, laboratory test results and remedial action plan. |
||
| Form 1 of 2 | |||
| WHAT
PROCEDURES WILL BE EMPLOYED IN THE STORAGE, TREATMENT, OR DISPOSAL OF HAZARDOUS WASTE OR HAZARDOUS SUBSTANCES? |
|
YES/No PROCEDURE |
YES/No PROCEDURE |
/ Manifest or Disposal Forms Used |
/ Drummed/over pack |
/ Bagged in two 6 mil bags, and labeled |
/ Transportation by Applicant |
/ Treatment (on/off site) Describe: |
/ Transportation by Independent Hauler |
| PROPERTY INFORMATION | |
| Describe in detail the property to be remediated, including exact address, description of property lines, etc. | |
| Describe in detail any surrounding/adjacent properties, including any waterways. | |
| Has an Environmental Audit (Phase I, Phase II, etc.) been performed on the contaminated site? YES NO | |
| INDEPENDENT CONSULTANTS | |
| If independent sampling or analysis is employed, please give name(s) and Address(es) of consultants. | |
|
Name Contact Person Address City, State, Zip Telephone # |
Name Contact Person Address City, State, Zip Telephone # |
|
Name Contact Person Address City, State, Zip Telephone # |
Name Contact Person Address City, State, Zip Telephone # |
| REGULATORY AGENCY(IES) | |
| List the regulatory agency(ies) that have direct jurisdiction over this project: | |
|
Name Contact Person Address City, State, Zip Telephone # |
Name Contact Person Address City, State, Zip Telephone # |
| APPLICANTS SIGNATURE | |
| Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing false, incomplete, or misleading information may be guilty of a felony or misdemeanor and subject to appropriate prosecution. | |
| Applicant’s Signature: | Date: / / |
| Form 2 of 2 | |
COMPANY NAME: ________________________________
COMPANY ADDRESS:
_____________________________
CITY: ___________________STATE:_____ZIP:_________
COMPANY CONTACT: _____________________________
PHONE: (____)____-________ FAX: (____)____-________
If
you do not have access to a fax machine please mail this completed form
to the
address below. You will then receive a quote by return mail and or by
phone as
soon as possible!
ATTN: BILL LOHMAN,
LEGENDS ENVIRONMENTAL INSURANCE, LLC.
1305 GENE AUTRY WAY ANAHEIM, CA 92805
PHONE NO. (800) 992-6999 FAX NO. (800)
999-3987.
(Please select choice of returned
quote)
[ ] - Return quote
by mail - [ ] - Return
quote by phone -
[ ] - Both -
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