Step Two: This page is all inclusive and conclusive, it includes
the introduction, submission list, and the five different applications.
You will need at least three of them. Please print the forms below by
clicking on the "print button" in your browser. Complete and fax them to
(800) 999-3987. You will then receive a FREE, no obligation quote,
within 2 business days.

Storage Tank Program Quote

The applications are mostly one page each and are each on
different pages. Once printed, they will be self explanatory.
Should you need any help in completing these forms please
contact Bill Lohman at (800) 992-6999

The Storage Tank program was developed to provide Pollution Liability coverage
for UST's (Underground Storage Tanks) and AST's (Above Ground Storage
Tanks) containing petroleum and petroleum related products. This policy meets
the requirements for the insured to receive an EPA Certificate of Insurance,
provided they maintain compliance. Coverage is on a claims made basis.
The policy includes legal defense cost , up to $100,000 per incident.

Some Potential Insured Categories:
1. Petroleum Marketers
2. Service Stations
3. Underground Tank Owner/Operators
4. Trucking & Distributing Operations
5. Fuel Distribution Fleet Facilities and Garages

SUBMISSION DOCUMENT GUIDELINES
1. Complete the Pollution Insurance Application for ,both, AST's and UST's.
2. Complete the Storage Tank Location Information Supplement or EACH Site,
both, AST's &UST's.
3. Complete: Underground tank Data Sheet for "all" UST's.
4. Complete: Above Ground Tank Data Sheet for "all" AST's.
5. Complete: Above Ground Tank System Questionnaire for each AST Site.
6. Complete: UST Management Summary if 10 or more sites are being submitted.

SUPPLEMENTAL DATA SUBMISSION FOR BOTH AST's and UST's.
1. Copies of the most recent Tank/Line Testing or Subsurface Assessments
performed for each Site.
2. Most recent Year End Financial Statement.
3. Complete loss history, including all reports, analytical data, regulatory and
consultants correspondence.



POLLUTION LIABILITY INSURANCE APPLICATION FOR
UNDERGROUND / ABOVE GROUND STORAGE TANKS

1. Applicant Name: _________________________________________
Address: _________________________________________________
City: _________________County: _______________ State: _________
Zip __________ Phone: ________________ FAX _________________
Contact Person: ___________________________________________

2. What is the date your business was established? _______________

3. Type of operation (check all that apply):

______tank owner ______tank operator
______ jobber ______Lessee/dealer
______owner/dealer ______ other: ___________________________

4. Are you a subsidiary of another company?_____ If yes, please explain:
________________________________________________________________
________________________________________________________________
________________________________________________________________

5. List all required additional insured's and their relationship to the applicant:
________________________________________________________________
________________________________________________________________
________________________________________________________________

6. Limits Requested (subject to availability end company discretion)
____________________ per pollution incident
____________________ policy aggregate

7. Deductible requested: $____________per pollution incident
(a minimum deductible of $5,000 is required)

8. Defense Costs Limits:

_______ $100,000 _______ $200,000 _______ $500,000
Other: ______________________

9. At the time of this application are you aware of any pollution related losses or
incidents, of any kind, at any site being considered for coverage?_______ If yes,
please explain (attach additional sheets if necessary). _____________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

10. Describe your inventory reconciliation program.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

11. Tank and Pipe Testing Program

Do you have a formalized tank end pipe testing program? _______If yes, who
performs the testing, how often is testing done and what type of system is utilized?
Attach a copy of all tank/pipe tests results performed . in the last 24 months.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

12. Tank and Piping Replacement Program

Provide a schedule of all tanks end piping replaced in the last three years,
including manufacturer and equipment type. Include information on any overfill
protection, spill containment and leak detection equipment.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

ATTACH ADDITIONAL SHEETS IF NECESSARY

13. REQUIRED ATTACHMENTS:

a. Form TLP 00 01 - Storage Tank Location Information Supplement completed
for each site where you are applying for coverage.
b. West recent year end financial statement.
c. Form UST 00 01 - Underground Tank Data Sheet for all USTs
d. Form AST 00 01 - Above Ground Tank Date Sheet for all ASTs
e. Form IST 00 02 - The Above Ground Tank: system Questionnaire if AST
coverage is sought.

WARRANTY: I understand and agree that insurance is provided based upon my
warranty of the answers to the questions listed in this application and explication
forms attached to this application, as well as statements made in other
information I have provided as Part of the application process. I further agree that
any material misstatement or concealment will void coverage on my behalf.

I understand that coverage to be issued will be on a claims made and
reported basis.

Completion of the applications does not bind either the applicant or the company
to insurance coverage.

Notice to New York, Kentucky and Ohio 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 act which is a crime.


------------------------------------ ---------------
Applicant's Signature & title Date

 

UNDERGROUND TANK DATA SHEET - FORM UST 00-01

Applicant : _________________________________________________
Site Name:_______________________________
Site Use: _________________________
Address:___________________________City:____________________
State: _____________Zip:_____________
Contact Person: _________________________Phone:_____________
Site Owner: ______________________________
Site Operator: ______________________
Tank Owner:______________________________

Complete the information required below for each tank.

TANKS	TANK	TANK	TANK	TANK
TANK I. D. NO.
PRODUCT STORED
CAPACITY (GALS.) - STATE IF COMPARTMENTALIZED
YEAR CONSTRUCTED
CONSTRUCTION CODE
LEAK DETECTION CODE
OVERFILL PROTECTION
SPILL CONTAINMENT (YES/NO)
PIPING/PUMP
YEAR INSTALLED
CONSTRUCTION CODE
PRESSURE OR SUCTION
LINE LEAK DETECTOR / FLOW RESTRICTOR

TANK PIPE CONSTRUCTION

LEAK DETECTION

OVERFILL PROTECTION

BS BARE STEEL AGM - AUTOMATIC GROUND WATER MONITOR'G BFV- BALL FLOAT
VALVE ON VENT LINE FRP FIBERGLASS MGM - MANUAL GROUND WATER MONITORING
DTF - DROP TUBE FLOW RESTRICTURE CPS CATHODICALLY PROTECTED STEEL AVM -
AUTOMATIC VAPOR MONITORING N/A _ NOT APPLICABLE STIP3 STEEL TANK INSTITUTE
T.P. MVM - MANUAL VAPOR MONITORING NONE - NO OVERFILL PROTECTION FLS
FIBERGLASS LINED STEEL AUT - AUTOMATIC TANK GAUGING SYSTEM FCS FIBERGLASS
COATED STEEL MIC - MANUAL INVENTORY CONTROL BI BLACK IRON SIR - STATISTICAL
INVENTORY RECONCILIATION COP COPPER PLT - PRECISION LEAK TEST GV
GALVANIZED STEEL (ALL DOUBLE WALLED ITEMS SHOULD USE A "DW" PREFIX, I.E.,
DWFRP = DOUBLE WALLED FIBERGLASS)



 STORAGE TANK LOCATION INFORMATION SUPPLEMENT

Applicant____________________________________Site # _________
Site Address___________________City__________State____ZIP________

1. In addition to the storage systems listed on the tank data sheet(s).
Are any other storage tanks (above ground or underground), vent lines
or product lines present? _______ If yes, please attach full details.

2. What year were storage tanks initially located at this site? ___________

3. What is the approximate annual through put at this site? _________gallons

4. a. Is the site within 100 feet of the following? (Check all that apply)
________Bodies of water _________Water wells __________Streams

5. Has any subsurface assessment related to the following been completed
at this facility? (Check all that apply)

____Property transaction ____Suspected Release ____Tank Removal
____Risk management ____Confirmed release ____Failed Tank Test
____Tank In-place abandonment _____Detected release
____Hydrocarbon release discovered on adjacent property
____Inventory Shortage
____Other (attach explanation)
____N/A

6. Has this site been identified on any federal, state or local environmental
agency list due to a confirmed or suspected discharge of pollutants?____
If yes, provide attach explanation and complete copies of all data,
reports, and regulatory correspondence.

7. Approximate depth to groundwater at this site:
____less than 10 feet _____10 to 20 feet
____20.1 to 50 feet _____Greater than 50 feet

8. Specify type of drinking water sources, both on site and
off site that exist within 1/4 mile? (check all that apply)
Your premises: _____well _____ City/Public
Neighboring properties: _____well and/or _____ City/Public

9. SURROUNDING ACTIVITY:
a. Are you aware of any environmental clean ups or investigations within
1/4 mile of your site? _________
b. Are you aware of any construction operations involving excavation
being performed on any neighboring property? ______

10. Is, or was, this site covered by another carrier's pollution liability
policy? _____If yes, provide details showing the carrier, dates of
coverage and proof of retroactive date of coverage.



ABOVE GROUND TANK DATA SHEET
SITE NO. :__________

Applicant: __________________________________
Site Name: _________________________________
Site Use: _________________________
Address:________________________City______________State ___ZIP_____
Contact Person: __________________________Phone: __________________
Site Owner: ____________________________Site Operator:_______________
Tank Owner: ________________________________

Complete the information required below for each tank.
Instructions for completing this application are attached. All codes that are
needed are included. Do not combine tanks from more than one site on a
single sheet. You may use as many copies of this form as you need to
complete each site.

TANKS	TANK	TANK	TANK	TANK
TANK I.D. NO.
PRODUCT STORED
CAPACITY (GALS)
YEAR CONSTRUCTED
CONSTRUCTION CODE
HORIZONTAL.VERTICAL OR SKID MOUNTED
INTERNAL PROTECTION
DIKING CONSTRUCTION
DIKING CAPACITY
OVERFILL PREVENTION
LEVEL DETECTION

PIPING/PUMP
YEAR INSTALLED
CONSTRUCTION CODE
% UNDERGROUND

ABOVE GROUND TANK SYSTEM SITE QUESTIONNAIRE
SITE NO. :__________

Applicant's Name ________________________________________________
Site Address:____________________________________________________

1. Describe facility security including after-hours security:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

2. How is the facility serviced?
(pipeline, river, ocean, harbor, common carrier, etc.)
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

3. Describe tank cleaning, inspection and testing procedures and how often
those procedures are conducted: _____________________________________
_______________________________________________________________
_______________________________________________________________

4. Have any tanks and/or lines been removed or taken out of service on a
permanent or temporary basis?______ If yes, provide copies of clean closure
documentation.

5. Has below ground piping at this facility been tested for tightness in the last 12
months? _____ If yes, provide a complete copy of the results.

6. Are tanks diked? _______If yes, describe construction, capacity etc.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

7. Distance to nearest surface water (lakes, rivers, streams etc.) and identify each
by name:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________