Pollution Liability Insurance Application

Important: Please complete all sections thoroughly. Fields marked with * are required. This application must be completed by an authorized representative of the company seeking coverage.

🔗 Alliance iCOS™ Integration Available

Connect this application to your iCOS™ dashboard for automated compliance tracking, environmental monitoring, and streamlined claims management. Contact your Alliance representative for integration setup.

1. Applicant Information

Company Legal Name *

DBA/Trade Name

Business Address *

City *

State *

ZIP Code *

Phone *

Email *

Website

Federal Tax ID *

Years in Business *

Entity Type *

Primary Contact Person *

📊 Environmental Compliance Tracking

Alliance's iCOS™ platform can automatically track your environmental compliance requirements, monitor permit status, and provide real-time alerts for regulatory changes affecting your operations.

3. Coverage Requirements

Desired Coverage Limit *

Preferred Deductible *

Specific Coverage Needs (Check all that apply)

Environmental Cleanup Costs

Third-Party Bodily Injury/Property Damage

Legal Defense Costs

Regulatory Action Coverage

Transportation Coverage

Business Interruption

Coverage Territory Required

4. Environmental History

Have you ever had an environmental claim or incident? *

Yes No

If yes, provide details of all environmental claims, incidents, or violations in the past 10 years

Any current or pending environmental violations or regulatory actions? *

Yes No

If yes, provide details

Previous Environmental/Pollution Liability Insurance Coverage

5. Risk Management Practices

Environmental Management Systems

Written Environmental Procedures

Formal Training Program

Incident Reporting System

Regular Environmental Audits

Emergency Response Plan

Certifications and Licenses

List all relevant environmental certifications, licenses, and permits

Safety Record and Loss Prevention Measures

Subcontractor Environmental Management

🛡️ Remediation Resources

Access Alliance's network of certified environmental remediation specialists and emergency response teams through your iCOS™ platform. Pre-qualified vendors and 24/7 incident response coordination available to all members.

Applicant Certification and Signature

I hereby certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any misrepresentation or omission of material facts may void coverage. I authorize Alliance for Contractors and its insurance partners to investigate the information provided and obtain additional information as necessary for underwriting purposes.

I acknowledge that completion of this application does not bind coverage and that coverage is subject to underwriting approval and policy issuance.

Applicant Signature

Date

Print Name *

Title *

ALLIANCE FOR CONTRACTORS

Pollution Liability Insurance Application

🔗 Alliance iCOS™ Integration Available

1. Applicant Information

2. Business Operations

Types of Work Performed (Check all that apply)

Hazardous Materials Handled