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in your browser. Complete and fax the forms to (800) 999-3987.
You will receive a FREE, no obligation quote, within 2 business days.

Century Surety Group
Abatement Operations Pollutant Specific
Liability General Application

Client Information

Name : ______________________________________________
Address : _____________________________________________
Phone :_____________________ Fax : _____________________
Agent/Broker : _________________________________________
Address : ______________________________________________
Phone : ____________________ Fax : _____________________

Coverage Information

Limits Required : ____________________ Per Incident Aggregate
Deductible ________________ Per Covered Abatement incident
Proposed Effective Date : __________________

Please list limits that you carry for the following coverage's :
Commercial General Liability ______________________________
Commercial Auto Liability _______________________________

1) What pollutants are you planning to abate? __________________

2) Professional Liability :
a. Describe pre abatement and post abatement clearance sampling protocol :
____________________________________________________________
____________________________________________________________
b. The name of the firm(s) analyzing the samples : ____________________
____________________________________________________________
(include the firm reading and analyzing XRF output)
c. Do you have any staff Architects or Engineers who perform professional activities
associated with the abatement project? Yes/No _____________ What is the extent
of their professional activities associated with this project? ___________________
_________________________________________________________________
_________________________________________________________________

3) Contractors :
a. Do you require your contractor's to enter into a standard contract with you?_____
b. Do you require that all abatement be certified and licensed to perform the
abatement operations that you are requiring coverage for? _______
Do you require proof of certification? ________
c. Do you require that your contractors have evidence of Insurance? _______
What limits of insurance do you require that your contractors to maintain?
General Liability Commercial Limits : ____________________________
Pollution Liability Insurance Limits : _____________________________
Auto Liability Insurance Limits : ________________________________
d. Do you require that the contractor list you as an additional insured on
their policies? Yes / No ________

4) Housing, Abatement Information :
a. How many residential housing units will be abated?_________________
b. Do you own or lease any commercial or retail space? If so, please describe:
_____________________________________________________________
c. How long will it take to complete the abatement project? ________________
d. Do you follow the Federal, State, County, and/or Locale applicable
abatement guidelines? _________________

5) Loss Experience :
Please state your General Liability and Pollution loss experience for the past 5 years
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Representation
I/We state that the information contained herein is true and correct as of the date
this application is executed. It is understood that, along with all attachments, this
application will be the basis of any policy of insurance that might be subsequently
issued by the company.

It is hereby understood and agreed that any misrepresentation, nondisclosure,
concealment, omission, or breach of representations in this application shall be
binding upon the applicant and each and every proposed insured under any policy
which is issued pursuant to this application.

I/We understand that the company will rely upon the truth and accuracy of the
information and statement in this application made to it in deciding whether to
issue a policy.

By signing this form and tendering of premium dose not bind the applicant and/or
the Company to complete the insurance.

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.

Must be signed in ink and dated with titles of authorized personnel

Signature _____________________________________ date : ____________

Print name: _______________________________Title : _________________



Century Surety Group
Abatement Pollutant Specific Liability Policy
Specific project Application

Named Insured : __________________________________________________
Policy Number : ___________________________________________________

Project Information : Please provide the following information for each project you are
requesting to add to your policy for coverage. Completion of this form dose not bind
coverage. Our written acceptance for coverage to your agent is proof of coverage.

Name and address of location : __________________________________________
Name of owner : ____________________________________________
What are the projected start and finish dates : _____________________
How many units are being abated? _________________
How many total units are in the building? _________________
What material is being abated or removed? _______________________
Is clearance testing being conducted prior to reoccupation? _____________________
Your project number or ID : ____________________________

Name and address of location : __________________________________________
Name of owner : ____________________________________________
What are the projected start and finish dates : _____________________
How many units are being abated? _________________
How many total units are in the building? _________________
What material is being abated or removed? _______________________
Is clearance testing being conducted prior to reoccupation? _____________________
Your project number or ID : ____________________________

Name and address of location : __________________________________________
Name of owner : ____________________________________________
What are the projected start and finish dates : _____________________
How many units are being abated? _________________
How many total units are in the building? _________________
What material is being abated or removed? _______________________
Is clearance testing being conducted prior to reoccupation? _____________________
Your project number or ID : ____________________________

Name and address of location : __________________________________________
Name of owner : ____________________________________________
What are the projected start and finish dates : _____________________
How many units are being abated? _________________
How many total units are in the building? _________________
What material is being abated or removed? _______________________
Is clearance testing being conducted prior to reoccupation? _____________________
Your project number or ID : ____________________________

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.

Submitted by : ____________________________________ Title : _________________