Coverage available is pollution insurance on a claims-made form with four coverage
part options: (cov.. A) On-site clean-up; (Cov. B) Off-site cleanup; (Cov. C) Third party
bodily; injury and property damage including Cov. B) and Defense; and (Cov. D, E and F)
Historical Pollution Incidents on or from an Insured Site.

Section One

Name: _____________________________________________
Corp. __ Part __ Indiv __Other ___
Address: ________________________City _______________
State____ Zip _____ Phone: _______________ Fax:________________

Address of Insured Site if different from above.
Attach schedule for multiple Sites.

___________________________________________________________

Important - Attach a photocopy of a local map indicating property
locations for each Site specified.

Additional Insured
Name:_______________________________________ Interest _______________
Address: ________________________City _______________ State____ Zip _____

COVERAGE'S REQUESTED LIMITS REQUESTED
(Options: $100K,250K,500K,1MM or Exclude)

Historical Pollution Incidents
(please see note below)
A. On-site clean-up A. _______________ D. _______________
B. Off-site cleanup B. _______________ E. _______________
C. Third-party BI&PD(incl.Cov B)and Defense C. _______________ F. _______________

Deductible per Pollution Incident: $5K ____ $10K ____$25K ____ Other (specify) _________

Proposed Effective Date: ________ Retroactive Date: _______
(Provide proof of current Retro Date)

Note: Historical Pollution Incidents coverage options D, E and F will require that
corresponding Cov. A, B and/or C be made effective. further, an inspection will
need to be performed prior to making coverage's effective. The Cost of the
inspection will be clearly stated on the proposal. All quotations, unless
specifically noted, presume that no pollution conditions are known to exist
on or adjacent to the Insured Site and coverage's are for current operations
of the applicant.

Section Two

SLEEP SITE INFORMATION
Please complete this section for each Site.

1. Do you own_____ or Lease _____ the Site?

2. Are you the occupant of the Site? Yes___ No___ If no, or if there are other occupants than
you, please specify by name and a brief description of their operation:_____________________
___________________________________________________________________________

3. How long have you owned or leased this Site? _______ years.

4. What is the size of the Site? ________ acres.

5. What is the total square footage of the buildings and any exterior operations
on the:Site?_______ Parking lots? _______ Sq.ft.or number of parking spaces______

6. Describe operations at this Site:
Past __________________________________________________________________
Present________________________________________________________________
Future_________________________________________________________________

7. Are there any underground or above ground storage tanks on the Site? Yes___ No___

8. Does the total quantity of hazardous materials (including petroleum products) stored on the
Site exceed 50 gallons (liquids) or 1000 pounds (other materials)? Yes___ No___ If yes, a)
attach a complete list of hazardous materials including b) a description of the method of storage
and storage security and c) specify the average daily quantity stored for each listed material.

9. Is the Site within 1/4 mile of a stream, lake, pond, river or other surface water?Yes___ No___
If yes, please describe ________________________________________________________

10. Please indicate the drinking water source for the Site. Well water____ City water____

11. Please describe the operations on the property immediately adjacent to the Site.
North: ________________________________________________________________
East: _________________________________________________________________
South: ________________________________________________________________
West: _________________________________________________________________

12. Are you aware of any environmental assessment, report, audit, etc. that was prepared
for this Site? Yes___ No___ If yes, please attach a complete copy.

13. After appropriate inquiry, are you aware of any known or suspected contamination,
environmental impairment claim, enforcement action, government notice or lawsuit past or
present on the Site or adjacent properties? Yes___ No___If yes, please provide full details
including discovery dates and ultimate disposition of the issue(s) by attachment.

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

Completion of this form does not bind coverage. Applicant's acceptance of Company's quotation
is required prior to binding coverage and policy issuance.

I/We warrant the information contained herein is true and correct as of the date of this application and it along
with any attachments will be the basis of the policy of insurance and deemed incorporated therein, if the
Company accepts this application by issuing a policy. I/We further warrant that the Site(s) operations for which
this application is being made, unless specified in this application, are in compliance with all environmental laws
and regulations. It is agreed that any misrepresentation, non-disclosure, concealment, or breach of warranty in
this application shall be binding upon the applicant and every proposed insured under any policy which is issued
pursuant to this application.

____________________________  ________   ____________________________  ________
             APPLICANT'S SIGNATURE                DATE                   APPLICANT'S SIGNATURE                   DATE

_____________________________________   _____________________________________
               PRINT NAME AND TITLE                                                PRINT NAME AND TITLE