.

- PRIMARY APPLICATION ENVIRONMENTAL CONTRACTORS & CONSULTANTS – GL / CEC / PROFESSIONAL PACKAGE

INSTRUCTIONS

• Please answer all questions completely. If any question does not apply, please check “no" or state “N/A”• If additional space is required, please provide on separate sheet and reference the section and question number• This form must be signed and dated by an owner, partner, director / officer or principal of the Applicant

SUBMISSION REQUIREMENTS

1. Applicant’s website address, or a company brochure, describing their experience, skills and representative projects.2. Resumes or statement of qualifications for those employees who perform professional services (design, consulting, etc.)3. A copy or description of the Insured’s internal Peer Review or other Quality Assurance and Control Procedures.4. A copy of the cover page and table of contents for Applicant’s Safety & Health Plan.5. Currently valued insurance company loss runs for the current policy period plus three (3) prior years for any GL,

Contractors Pollution, Professional Liability and Excess policies held by the Applicant.Provide claim and loss details for any open claim or losses over $10,000 incurred.

SECTION I - APPLICANT

1. First Named Insured: Date: Mailing Address:City: State: Zip: Additional Locations: 1. (or attach add’l sheet) 2.

3. Website Address: www. Risk Management Contact: Title: Risk Management’s Email: Phone: Company is: Individual Partnership Corporation Limited Liability Corporation

Joint Venture (describe): Other (describe): 2. Date entity was established: Year environmental operations began: 3. In which states does the Applicant perform its work?4. In the past 5 years, percentage of work performed in New York State: % 5. In the past 5 years, has the Applicant performed any work in New York City (5 boroughs)? Yes No 6. Does the Applicant plan to perform future work in New York State or New York City? Yes No 7. Any acquisitions, mergers or discontinued operations in the last five (5) years? Yes No

If yes, please describe:

8. List all current and prior entities and affiliated or subsidiary companies to be included as additional NamedInsureds (include a general description and revenues for each) – attach separate sheet as necessary.

9. Total EmployeesPersonnel BreakdownArchitects: Environmental Engineers: Mechanical Engineers: Chemists: Field Personnel: Microbiologists: Civil / Structural Engineers: Geologists/Hydro Geologists: Principals / Owners: Clerical: H & S / Risk Managers: Supervisors & Foreman: Electrical Engineers: Industrial Hygienists: Other:

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SECTION II - COVERAGES

1. In-force coverage – OR provide full expiring policy forms & endorsements No Prior Coverage

General Liability Contractors Pollution Professional Liability Excess (See Excess App)

Carrier Effective Date Expiration Date Limits (Each / Agg) $ / $ $ / $ $ / $ $ Deductible / SIR $ $ $ $ CM / OCC – Retro Date CM Expiring Premium $ $ $ $

In-Force coverage – MOLD No Prior Mold Coverage

Contractors Pollution Liability Professional Liability Excess Covered Excluded Covered Excluded Covered Excluded Occurrence Claims Made

Mold Retro Date: Mold Retro Date: Sub-limited on XS Yes No Mold Deducible: $ Mold Deducible: $ XS Mold Limits: $

2. Requested Coverages – Effective Date:

General Liability

Contractors Environmental Professional Liability

Excess (See XS App)

Limits (Each / Agg) $ / $ $ / $ $ / $ $ Deductible / SIR $ $ $ $ Retroactive Date

3. Coverage Add-Ons Requested

EBL – Retro Date: Premises Environmental – S & A Hired & Non-Owned Auto (Additional Information Required) Project Specific Increase of Limits* Non-Owned Location – Retro Date Stop Gap (WA / WY / ND / OH / WV) Per Project General Aggregate Transportation Environmental Liability Premises Environmental – Full (Additional Information Required)

* If the Applicant requires project specific increased limits, please provide details of the project, and the limits required:

SECTION III – CLIENT TYPES / JOB SITES

1. REVENUE breakdown by Client Type / Job Site

INDUSTRIAL RESIDENTIAL / HABITATIONAL Manufacturing / Chemical Plant % Apartment / Dormitories % Petrochemical / Refineries % Single Family homes % Pipelines: % Condos / Townhouses % Natural Gas % Tract Housing % Petrochemical % Nursing Homes % Other: % Prisons / Correctional Facilities % Wastewater Sewage Plants % Potable Water Systems % COMMERCIAL / PUBLIC Other Processing Plants % Shopping Centers % Power Plants / Transformer Stations % Office/Warehouses % Other (please describe): % Parking Structures % Churches % INFRASTRUCTURE Sports / Convention % Airports & Runways % Schools / Colleges % Street/Roads % Hospitals % Bridges & Tunnels % Airport Terminals % Harbors / Piers / Ports / Dams % Hotels/Motels % Offshore Marine % Landfills / Disposal Facilities % MUNICIPAL / GOVERNMENTAL Mass Transit / Railroad % DOD / DOE / Federal / Homeland Security % Nuclear Facilities % State/Local %

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SECTION IV – OPERATIONS & REVENUES

1. Projected Gross Revenue

Projected Gross Revenue for the next 12 month period: $ Foreign: % Actual Gross Revenue for the 1st prior 12 month period: $ Foreign: % Actual Gross Revenue for the 2nd prior 12 month period: $ Foreign: %

2. Sub-contracted Work & Risk Transfer

a. Does the Applicant use sub-contractors or sub-consultants to perform any portion of its work? Yes No b. When relevant, does the Applicant require its subs to carry Pollution coverage? Yes No c. When subs are used, does the Applicant obtain Certificates of Insurance from the subs? Yes No d. Does the Applicant require subs to add them as Additional Insureds on their GL & Pollution

policies? Yes No e. What are the minimum Limits of Liability that the Applicant requires from its subs? General Liability: $ Contractors Pollution Liability: $ Professional Liability: $

3. Transportation Environmental Coverage a. Does the Applicant ever use 3rd Party Transportation Companies to transport their waste? Yes No If yes: i. Does the Applicant verify that the transporter is properly licensed and permitted? Yes No ii. Does the Applicant verify that the transporter’s insurance includes pollution and MCS-90? Yes No b. Is the Applicant seeking coverage for 1st Party Transportation Environmental Liability coverage? Yes No If yes, please complete the following: Total Number of Applicant’s vehicles hauling hazardous materials or potential contaminants, by type: Type of Vehicle No. of Units Type of Vehicle No. of Units

Private Passenger & Light Trucks: Extra Heavy Trucks or Truck Tractors: Medium Truck: Railcar or Rolling Stock: Heavy Trucks: Watercraft or Barge: c. Identify the materials that the Applicant transports: d. What is the average mileage per trip hauling potentially hazardous or polluting materials? e. Is the Applicant required to maintain an FMCSA Hazardous Materials Safety Permit? Yes No If yes, is that permit in good standing? Yes No f. Has the Applicant incurred a loss related to pollution in transportation within the last four years? Yes No

4. Waste Brokering or Arranging a. Does the Applicant select or recommend disposal sites on behalf of or for its clients? Yes No b. Does the Applicant take title to any waste or cargo at any time? Yes No c. Does the Applicant verify that the landfill / disposal site is properly classified to accept the waste? Yes No d. Does the Applicant verify that the landfill / disposal site is properly insured? Yes No

5. Premises Environmental Liability a. Do the Applicant’s facilities consist of offices and/or contractor’s yard only, with no Haz Mat or

processing activities? Yes No b. Which, if any, of the following occur at the Applicant’s owned or operated facilities: (check all the apply) Temporary Storage of Asbestos or LBP Materials Landfill or Waste Disposal Storage or Transfer Facility Small Quantity Generator –Conditionally Exempt Large Quantity Generator Testing Laboratories Manufacturing, Fabrication or Assembly Activities Underground Storage Tanks Air Emissions Fixed Base Operations (FBO) Ongoing Operation & Maintenance (O & M) of a facility for others

SECTION V – RISK MANAGEMENT AND BEST PRACTICES

1. Safety Practices

a. Does the Applicant have a written Safety & Health Plan for its on-premises and jobsite activities? Yes No b. Does the Applicant provide an industry-relevant Safety Training Program for its employees? Yes No c. Does the Applicant implement an Auto Safety and Vehicle Maintenance program, or DOT Safety

Management Plan? Yes No

IMPORTANT Please thoroughly complete the REVENUE BREAKDOWN SCHEDULE at the end of this Application. The sum of all Contracting & Consulting / Engineering revenues must equal your PROJECTED GROSS REVENUE for the next 12 months.

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2. Contractsa. Percentage of jobs performed under the following types of client agreement:

Insured’s Written Contract: % Letter Agreement: % Purchase Order: % Client’s Written Contract: % Verbal Agreement: % Other: %

b. How are non-standard client or sub-contractor agreements reviewed?Agent Review In-House Attorney Outside Attorney Staff (describe):

c. Does the Applicant utilize a Limitation of Liability of a specified dollar amount in its contracts? Yes No If yes, what is the amount: $

d. When consulting, do the Applicant’s reports include a disclaimer regarding 3rd party reliance? Yes No e. Does the Applicant utilize the ASTM E1527 Standard protocol when conducting Phase I ESA’s? Yes No f. Does the Applicant utilize a written contract with sub-contractors / sub-consultants 100% of the

time? Yes No 3. Operations and Procedures

a. Which of the following Risk Control / Operational Procedures does the Applicant commonly implement onprojects:

Project Specific Safety and Health Plans Excavation and Underground Utility Risk Prevention Plans Dust Control and Prevention Plans Soil – Waste – Hazmat Site Management Plans Storm Water Pollution Prevention Plans (SWPPP) Daily Toolbox or Tailgate Talks or Briefings

4. Quality Control and Quality Assurancea. Does the Applicant implement a Quality Control / Assurance Program for its construction

projects? Yes No b. Does the Applicant have a Quality Control / Assurance Program for its design / consulting

projects? Yes No c. Has the Applicant implemented a Risk Management Action Plan or Applied Best Practices

system? Yes No d. Indicate which of the following risk management and best practices are utilized by the Applicant:

Detailed Scope of Services (SOS) Dedicated Project Management Internal Peer Review of Reports Strategic Client /Project Selection Alternative Dispute Resolution Termination & Suspension Procedures Customer Service Department Client Satisfaction Surveys Other:

SECTION VI – MOLD, ASBESTOS AND LEAD BASED PAINT

1. For the immediate past four year period, have there been any known incidents, claims or othercircumstances concerning the existence, growth or presence of mold resulting from any of theApplicant’s previous work or services? Yes No If yes, please provide details re: Claimant, nature of claim, amount paid or estimated and current status:

2. Does the Applicant have contracting personnel on staff with licensing or certification in moldabatement? Yes No

3. Does the Applicant have professionals on staff with formal training in mold testing and assessment? Yes No 4. Is there an established protocol/practice for preventing mold & water intrusion on the Applicant’s jobs? Yes No5. Does the Applicant have licensed Asbestos and/or Lead-based Paint (LBP) Abatement Contractors on

staff? Yes No 6. Does the Applicant have licensed Asbestos and/or LBP Abatement Project Designers/Supervisors on

staff? Yes No 7. Does the Applicant have a Certified Lead-Safe Renovator (RRP) on staff? Yes No 8. Is the Applicant properly licensed for all types of asbestos and LBP work/services that it performs? Yes No

Please provide documentation of the above Qualifications, Protocols, Certifications, etc. as referenced – PRIOR TO BINDING

SECTION VII – CLAIM HISTORY

1. Has the Applicant or any staff member or employee of Applicant ever been subject to disciplinaryaction by authorities as a result of their professional or contracting activities? Yes No

2. With the last four (4) years, have any claims been previously made against the Applicant or reportedunder any General Liability, Contractors Pollution Liability or Professional Liability policies? Yes No If yes, please describe:

3. Is the Applicant aware of any fact, circumstance or situation which could reasonably be expected toresult in a claim being made against them or any other person or entity for whom coverage is beingsought? If yes, please describe: Yes No

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REVENUE BREAKDOWN SCHEDULE

PRODUCTS Designed and/or Sold by the Applicant - With and Without Installation (if any) Estimated Gross Revenue from Products Sold Product Designed and/or Sold by You with Installation Describe:

$

Product Design and/or Sold by You without Installation Describe:

$

REVENUE BREAKDOWN by Operational Classification

ENVIRONMENTAL CONTRACTING CLASSES

% Sub-contracted ↓ ENVIRONMENTAL CONTRACTING CLASSES

% Sub-contracted ↓

GROSS REVENUE

GROSS REVENUE

Asbestos and Lead Abatement (incl. related demo) - Residential or Habitational

PCB Removal

Asbestos and Lead Abatement (incl. related demo) - Commercial or Industrial

Phyto or Bio Remediation

Barrier or Liner Construction (not landfill) Pipeline Construction and Repair

Disposal Fees for Waste or HAZ Materials (Not packing, loading or hauling fees)

Recycling (Chemicals or Hazardous Materials)

Dredging (Pollution Related only) Sample Collection – Asbestos & Lead or Other

Drilling (Env. monitoring or treatment wells) Sample Collection – Soil or Groundwater

Emergency Response Cleanup/Spill Response Soil Remediation – Excavation/Dig & Haul

Groundwater Remediation Soil Remediation – In Situ

Hazardous Material Cleanup (NOT Soil or GW) Solar Installations (Photovoltaic and Hot Water):

- Residential or Habitational

Hazardous Waste Treatment (at job site) Solar Installations (Photovoltaic and Hot Water):

-Residential or Habitational New Tract Home Construction/ Development

Indoor Air/Radon Mitigation (non-Mold) Solar Installations (Photovoltaic and Hot Water):

- Commercial or Industrial

Industrial Cleaning (not tank or pipe) Superfund Remediation Contracting

Lab Packing (Facility Clean-out; Packaging/Loading) Tank and Pipe Cleaning (confined space)

Landfill Capping and Surface Maintenance Tank and Pipe Cleaning (remote/robotic)

Landfill Construction or Expansion Tank Installation & Removal – Aboveground Only

Landfill Liner Installation Tank Installation – Underground

Medical Waste Pickup and Transportation Tank Removal – Underground

Medical Waste Processing or Remediation Tank Maintenance and Repair

Mobile Incineration / Thermal Treatment / Solvent Distillation

Transportation/Haul Away of Wastes & Haz Mats (NOT Including Packing or Loading) [Does NOT include Well Field Saltwater Hauling]

Mold Remediation (incl. related demo) - Residential or Habitational

Waste Stream Treatment System Construction (not sewage or potable water treatment systems)

Mold Remediation (incl. related demo) - Commercial or Industrial

Wetland and Habitat Restoration Contracting

Other:

Wind Turbine Installation and Maintenance

Other:

TOTAL ENVIRONMENTAL CONTRACTING REVENUE: $

Please read through all operational classifications within each category and identify those services which you provide. Then allocate 100% of your projected Gross Revenue for the next 12 months (from Page 3) to the specific classifications of Contracting and Consulting/Engineering Services you perform. For each, indicate the Gross Revenue generated from that Classification, and the % performed by sub-contractors or sub-consultants.

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REVENUE BREAKDOWN SCHEDULE (Section IV Continued)

NON-ENVIRONMENTAL CONTRACTING CLASSES

% Sub-contracted ↓ NON- ENVIRONMENTAL CONTRACTING CLASSES

% Sub-contracted ↓

GROSS REVENUE

GROSS REVENUE

Bridge Construction Masonry – Stone / Brick

Carpet Cleaning (Not as Fire/Water Restoration) Oil and Gas Leasing

Concrete – Flatwork Operation and Maintenance (facilities of others)

Demolition (interior, not part of Abatement) Painting and Coatings Application (NOT Bridges)

Demolition-Structural (1 to 3 stories) Painting and Coatings – BRIDGES

Demolition-Structural (Over 3 stories) Paving – Public Streets and Roadways

Dredging (deepening or widening of waterways) Pesticide and Herbicide Application (AERIAL)

Drilling (oil/gas) Pesticide, Herbicide and Fertilizer Application (NOT Aerial)

Drilling (water wells) Pile Driving

Drywall Plastering or Stucco

Electrical Plumbing – Not Fire Suppression / Sprinklers

Excavation or Grading Potable Water Treatment System Construction

Finish Carpentry Railroad Construction and Maintenance

Fire Suppression/Sprinklers Installation Roofing

Flooring Sandblasting

Foundation Construction Scaffold Erection

Framing & Carpentry (general) Sewage Treatment Plant Construction & Maint.

General Contractor Sewer and Septic Cleaning & Maintenance

Glazier / Glass and Window Steel Erection

Home Building / Residential Developers Temporary Employment Agencies / Labor Force

HVAC and Mechanical Refrigeration Transportation / Hauling (Non-Environmental)

Insulation (no abatement) Transportation / Hauling – Well Field Saltwater

Landscaping Unexploded Ordinance / UXO Removal

Logging Waterproofing

Marine Construction and Marine Activities OTHER:

TOTAL NON-ENVIRONMENTAL CONTRACTING REVENUE: $

ENERGY - Oil & Gas CONTRACTING CLASSES

% Sub-contracted ↓ ENERGY - Oil & Gas CONSULTING AND ENGINEERING CLASSES

% Sub-contracted ↓

GROSS REVENUE

GROSS REVENUE

Roustabout Oilfield Consulting – Observe & Report Only

Rat Hole Drilling Oilfield Consulting – Direct Supervision

Pad Site and Road Construction or Maintenance Geophysical / Reservoir Engineering

Pipeline / Gathering Line Construction / Maintenance Pipeline / Gathering Line Layout and Design

Downhole, Over the-Hole or Production Activities Oil and Gas Well Engineering

OTHER: OTHER:

TOTAL NON-ENVIRONMENTAL CONTRACTING REVENUE: $

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REVENUE BREAKDOWN SCHEDULE (Section IV Continued)

ENVIRONMENTAL CONSULTING AND ENGINEERING CLASSES

% Sub-contracted ↓ ENVIRONMENTAL CONSULTING AND ENGINEERING CLASSES

% Sub-contracted ↓

GROSS REVENUE

GROSS REVENUE

Air Quality Testing and Monitoring (non-Mold) Lab Testing / Analysis (environmental)

Asbestos and Lead-Based Paint Assessment, Remedial Design and Monitoring Mold Inspection and Assessment

Construction or Project Management – Agency (on environmental projects) Phase I or Transaction Screen

Construction or Project Management – At Risk (on environmental projects) Phase II – Subsurface Investigation

Decommissioning Design for Radioactive & Nuclear Facilities Phase III – Remedial Design Plans and Specs

Energy Efficiency Consulting Pipeline Integrity Testing

Environmental Compliance Training Radon Consulting

Environmental Impact Studies Regulatory Consulting / Permitting

Expert Witness / Litigation Support (environmental) Remediation Oversight / Management

Feasibility Studies or Reports without Design Solar / Photovoltaic System Layout and Design

Geology & Hydrogeology (100% Environmental) Surveying in Support of Environmental Reports

Geophysical Assessments (100% Environmental) Non-Mining / Non-Oil & Gas Tanks – UST/AST System Design

Geotechnical (100% Environmental) - Related to Remediation System Design or Constr. Tanks – UST/AST Testing

Hazardous Materials Consulting Waste Brokering / Disposal Site Selection

Health and Safety Training Wetlands and Wildlife Consulting or Design

Industrial Hygiene Consulting OTHER:

TOTAL ENVIRONMENTAL CONSULTING REVENUE: $

NON-ENVIRONMENTAL CONSULTING AND ENGINEERING CLASSES

% Sub-contracted ↓ NON-ENVIRONMENTAL CONSULTING AND ENGINEERING CLASSES

% Sub-contracted ↓

GROSS REVENUE

GROSS REVENUE

Architectural Design Land Surveying (non-environmental)

Building Condition Inspectors / R.E. Audits Landscape Architecture

Civil Engineering Marine Engineering

Construction or Project Management – Agency (non-environmental projects) Mechanical Engineering

Construction or Project Management – At Risk (non-environmental projects) Mining Engineering

Electrical Engineering (except Photovoltaic) Pipeline Design

Geology and Hydrogeology (Non Environmental) Process Engineering - Potable & Sewer / Waste Water Facilities

Geophysical Assessments (Non Environmental) Mining and/or Oil & Gas

Process Engineering – Petroleum, Chemical & Food Industries

Geotechnical Engineering (building construction, foundation, structural or slope stability related) Software Design / Programming

HVAC Engineering Structural Engineering

Lab Analysis / Construction Materials Testing (non-environmental) OTHER:

TOTAL NON-ENVIRONMENTAL CONSULTING REVENUE: $

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FRAUD STATEMENT AND SIGNATURE SECTIONS

The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder.

The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.

*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company.

FRAUD NOTICE STATEMENTS

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PA, RI, TN, VA, WA AND WV).

APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.

APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.

APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).

APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.

APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.

APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

APPLICABLE IN VERMONT: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.

APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. NAME (PLEASE PRINT/TYPE) TITLE

(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE DIRECTOR)

____________________________________________________ SIGNATURE DATE

SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT PRODUCER AGENCY (If this is a Florida Risk, Producer means Florida Licensed Agent)

PRODUCER LICENSE NUMBER (If this a Florida Risk, Producer means Florida Licensed Agent)

ADDRESS (STREET, CITY, STATE, ZIP)

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