S&A Pollution Application

Please fill out the form below and hit the submit at the bottom of the page.

To download a printable version of the application, click here

NOTE: PLEASE COMPLETE AN APPLICATION FOR EACH SITE TO BE INSURED. THE WORDS “YOU” AND “YOUR” REFER TO THE NAMED INSURED AND ANY ADDITIONAL INSURED

Applicant Information
Coverage Requested
2. Policy Period

Preferred Risk requires a Clean Marina Designation from a recognized State agency or Trade Group.

$
5. Existing pollution or environmental insurance coverage
History
Surrounding Environment
Environmental Controls
Fueling Operations
Repair or Service Operations
Pump-Out Stations
Risk Management Administration
Certification

I have read the above Supplemental Application. I hereby certify that the statements made herein and the data and information supplied herein are true, accurate and complete. These statements, information and data are given for the specific purpose of inducing the insurer to issue pollution liability insurance coverage. It is agreed that if any state, information or data given in the Supplemental Application is materially false, inaccurate or incomplete, the insurer may deny coverage or cancel the policy.

FOR NEW YORK 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 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.