NOTE: Please complete an application for each site to be insured. The words "You" and "Your" refer to the named and any additional insured.

Applicant Information:

1. Insured Name:

Address:

City: State: Zip:

 

---

Contact Person:

 

Title:

Phone Number:

---

Insured is:
Corporation
Partnership
Individual
Joint Venture
Other

---

Year established in business:

 

---

Description of operations:

 

2. Is the insured site owned or controlled by another Corporation?

Yes No
If Yes, by:

3. List other named insureds and brief description of operations for each:

Named Insured:
Operations:

Named Insured:
Operations:

Named Insured:
Operations:

Named Insured:
Operations:

4. List additional insured(s) and describe the relationship to the named insured:

Additional Insured:
Relationship:

Additional Insured:
Relationship:

Additional Insured:
Relationship:

Coverage Requested

1. Policy: New Renewal

2. Policy Period: From: To:

3. Limits of insurance requested:

a. Per incident: $

b. Aggregate: $

4. Deductible requested: $

5. Existing pollution or environmental insurance coverage:

a. Do you currently have pollution liability coverage? Yes No

b. If yes, is the policy written on occurrence claims-made basis?

c. State the retroactive date of enforce claims-made coverage:

History

1. Are you currently in compliance with federal, state and local environmental laws?

Yes No
If no, explain:

2. Has the company during the last five years been cited or prosecuted for any violation of any standard or law relating to the release of a substance into the environment?

Yes No
If yes, explain:

3. Have you ever been sued or requested to pay any damages or to perform any clean up activities with respect to any actual or alleged pollution incident?

Yes No
If yes, attach a full explanation including the date of incident.

4. Have there been any emissions, discharges, releases or escapes of pollutants or other substances above permissible levels at any site for which this Application is being made?

Yes No
If yes, explain:

5. List all environmental impairment losses paid or incurred within the past three years:

Date: Amount: $
Description:

6. Are you aware of any fact or circumstance that might lead you to a claim under the policy it it were to be issued?

Yes No
If yes, explain:

Chemical Use

1. Provide a list of pesticides, herbicides and fungicides you have used on the golf course in the last two years. Include quantity of each chemical used.

If you have used any of the following chemicals in the last two years please provide a narrative of application frequency and quantity:

A. DBCP Yes No
Application Frequency and Quantity:

B. Diazinon Yes No
Application Frequency and Quantity:

C. Aldicarb Yes No
Application Frequency and Quantity:

D. Endrin Yes No
Application Frequency and Quantity:

E. DDT Yes No
Application Frequency and Quantity:

F. Chlordane Yes No
Application Frequency and Quantity:

G. Heptachlor Yes No
Application Frequency and Quantity:

2. Do you apply pesticides, herbicides or fungicides above six feet?

Yes No

3. Do you apply pesticides, herbicides or fungicides through your irrigation system?

Yes No

4. Do you post any warning signs during application of chemicals?

Yes No

5. Have you ever seriously damaged a green or fairway, or killed wildlife as a result of over application of chemicals?

Yes No

6. Is there a designation on-site storage area for chemicals? Yes No

 

Water Usage

1. What is the estimated watered turf grass acreage?

<75 acres
75-100 acres
>150 + acres

2. How much water do you typically use in one day?

<250,000 gallons per day
250,000-5000,000 gallons per day
>500,000 gallons per day

3. Where do you obtain your water?

municipal supply
owned well(s)
reservoir/pond/lake
wastewater treatment plant(s)

 

Surrounding Environment

1. Are there perennial (i.e. running) streams on the premises? Yes No

2. Are there drinking water wells on-site or within 1/2 mile? Yes No

3. Are there protected wetlands or coastal zones adjoining the property?

Yes No

4. Has the property previously been used for industrial purposes?

Yes No

5. Has the property previously been used as a landfill for waste disposal?

Yes No

6. What is the percentage of fairways bordered by residences? %

 

Controls

1. Do you test surface waters on the premises for water quality?

Yes No

2. Do you employ integrated pest management (IPM) and/or turfgrass management system (TMS) techniques?

Yes No

3. Is the golf course open to non-gold related activities (i.e. fishing, nature walks, picnics, etc.)?

Yes No

4. Have you conducted any risk assessments, environmental impact studies or turf management programs?

Yes No
If yes, please describe or provide copies:

 

Training

1. How many turf managers (i.e. greenskeepers/superintendents) do you employ?

None
1
2 or more

2. Are any turf managers certified to apply pesticides? Yes No

3. Do you have formal record keeping procedures regarding agricultural chemical usage?

Yes No

 

Storage Tanks

1. Are there currently any underground storage tanks (UST's) or above ground storage tanks (AST's) on the property that are used to store gasoline, fuel oil, or pesticides?

Yes No
If yes, provide a report indicating the number, age, volume and type of tanks, and materials stored. Note: You must supply current UST integrity test results in order for coverage to be considered for the UST's.

 

	Capacity	Age	Construction	Contents	AST/UST
Tank 1
Tank 2
Tank 3

2. Has any underground storage tank(s) been closed at this location within the last 10 years?

Yes No
If yes, submit a copy of closure documents indicating number of tanks, date of closure, and results of closure:

 

Miscellaneous

1. Do you store or sue chlorine gas on-site? Yes No

2. Do you operate any dry cleaning machines on the premises?

Yes No

 

---

 

Declaration and Signature:

The undersigned declares that to the best of his or her knowledge and belief the statements set forth herein are true. Although the undersigned of this application does not bind the undersigned on behalf of the Organization or its directors, officers or other Inured Persons to effect insurance, the undersigned agrees that this application and its attachments shall be the basis of the contract should a policy be issued and shall be attached to and form part of the policy. The Company is hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary.

Any persons who, knowingly and with intent to defraud any insurance company or other persons, files an application for insurance, containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

 

Dated________________ Signed____________________________________Title__________________________