Legends Environmental Insurance/Landfill & Waste Quote

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.

Landfill & Waste Facility Liability Insurance Quote

To receive this quote you will need to complete all three 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 RETROACTIVE DATE / /
DEDUCTIBLE DESIRED		LIMITS OF LIABILITY REQUESTED
$10,000 $25,000 $50,000 Other $____ $1,000,000 per occurrence / $1,000,000 aggregate $ ____ / $ ____ GENERAL INFORMATION - Explain all "YES" responses
YES / NO		YES / NO
/ Has the Applicant, during the last five (5) years, had any reportable releases or spills of hazardous substances or pollutants as defined by applicable environmental statutes or regulations? If YES,describe in detail.		/ Dose Applicant have Fire Protection Plan? If YES, attach copy. / Dose Applicant have a documented inspection Program? If YES, attach copy. / Dose Applicant have an Emergency Responce Plan? If Yes, attach copy.

PROVIDE THE FOLLOWING INFORMATION ON WASTE SENT OFF SITE.
Type	Mode of Transport	Quantity	Disposal site or waste transfer facility
			Name Address City, State, Zip
			Name Address City, State, Zip
			Name Address City, State, Zip
			Name Address City, State, Zip
			Name Address City, State, Zip
SUPPLEMENTAL INFORMATION - Required from all Applicants
Attach each item listed to Application Copies of Environmental Impairment Liability policies for the past three (3) years. Copies of any environmental surveys / audits conducted at the location. Provide a complete descripition of the Applicant's operation (include a diagram of the company structure) EPA Identificcation numbers
Form 1 of 3

LIST OF LOCATIONS TO BE COVERED
Location One :	Name Address City, State, Zip			Description Of Operations		Age Of Facility
Description Of Past Occupancies And Land Use				Description Of Surrounding Environment And Land Use
Permits And Ground Water Monitoring. POTW NPDES AIR Stormwater
Dose Location Have:	On-site ground water monitoring wells? Yes NO If YES, how many? If YES, provide monitoring results from past 4 samples & a map showing the location of the wells & groundwater flow direction.
Description of nearby surface water bodies (e.g., streams, lakes, wetlands):
Description of any protected environments in the area (parks, wildlife reserves, etc.):
Quantity of Material					Method of Storage
Description		Per Year	Any One Time		Type(e.g., drum, etc.)	Secondary Containment



Description of all above/underground storage tanks on-site:
Tank #	Contents	Construction	Capacity	Age	AST or UST	Secondary Containment
Example:	Diesel	Bare Steel	5,000 gal	5 years	AST	110% Volume - Poured Concrete




Explain any tank inventory control and/or testing methods used (Attach latest tank test results):
Location Two :	Name Address City, State, Zip			Description Of Operations		Age Of Facility
Description Of Past Occupancies And Land Use				Description Of Surrounding Environment And Land Use
Permits And Ground Water Monitoring. POTW NPDES AIR Stormwater
Dose Location Have:	On-site ground water monitoring wells? Yes NO If YES, how many? If YES, provide monitoring results from past 4 samples & a map showing the location of the wells & groundwater flow direction.
Description of nearby surface water bodies (e.g., streams, lakes, wetlands):
Description of any protected environments in the area (parks, wildlife reserves, etc.):
Form 2 0f 3

Description of all raw/hazardous materials used or stored on-site(planting agents, degreasers, cleaning solvents, etc.):
Quantity of Material					Method of Storage
Description		Per Year	Any One Time		Type(e.g., drum, etc.)	Secondary Containment



Description of all above/underground storage tanks on-site:
Tank #	Contents	Construction	Capacity	Age	AST or UST	Secondary Containment
Example:	Diesel	Bare Steel	5,000 gal	5 years	AST	110% Volume - Poured Concrete




Explain any tank inventory control and/or testing methods used (Attach latest tank test results):
Additional Comments/Locations:
APPLICANT’S 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 3 of 3

COMPANY NAME: ________________________________

COMPANY ADDRESS: _____________________________

CITY: ___________________STATE:_____ZIP:_________

COMPANY CONTACT: _____________________________

PHONE: (____)____-________ FAX: (____)____-________