- PROJECT SPECIFIC SUPPLEMENTAL APPLICATION
ENVIRONMENTAL CONTRACTORS AND CONSULTANTS – GL / CEC / PROFESSIONAL PACKAGE
• 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.
SECTION I – PROJECT INFORMATION
Description of sub-contracted services:
Requested Coverages, Limits and Retention (if applicable):
Please provide a copy of the contract or other project information that confirms the Limits of Liability requirements.
This application is to be used in conjunction with a completed E-PAC Primary Application. 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
_________________________________________________
APPLICANT: (Signature of Owner of Officer of corporation)
APPLICANT: (Print Name and Title)
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© 2019 Philadelphia Consolidated Holding Corp.
