Pollution Liability Insurance for SITE SPECIFIC OPERATIONS - INSURANCE INTAKE FORM

POLLUTION LIABILITY INSURANCE INTAKE PAGE

This intake page is intended for stationary operations with environmental or pollution liability exposures, including gas stations, fuel sites, treatment plants, underground storage tanks, industrial facilities, and fixed-location environmental risks. Follow Steps 1-5 below.

Important Form Notice: This intake process is intended for stationary site-specific pollution liability exposures such as gas stations, convenience stores with fuel sales, underground storage tanks, aboveground storage tanks, treatment plants, industrial facilities, petroleum storage, chemical storage, wastewater operations, and other fixed-location environmental risks. Completion of this intake process does not guarantee coverage, pricing, or insurability.

Complete, Save & Upload the Pollution Liability Application

First, complete the Pollution Liability Insurance application. It will open in a new browser tab so you can return here after saving it.

After completing the application, save the completed PDF to your computer. Then return to this page and upload it in Step 5.

Important: No signatures are required on this application for quoting purposes. Please complete the application as thoroughly as possible, save it, and upload it in Step 5. Signatures may be requested later by an insurance carrier if coverage is offered and you decide to proceed.

Click Here First Open Pollution Application ➜

STATIONARY SITES Use this process for fixed-location operations such as gas stations, treatment plants, industrial sites, fuel locations, and environmental exposure properties.

STORAGE TANKS Include underground storage tanks, aboveground storage tanks, petroleum storage, chemical storage, and related tank exposures.

TREATMENT PLANTS Water treatment, wastewater treatment, processing facilities, utilities, and similar stationary environmental operations can use this intake process.

PROPERTY RISKS Property owners, landlords, developers, brownfields, redevelopment sites, and contaminated property exposures should include all known site information.

REMARKS Use remarks to explain tanks, site history, spills, prior contamination, cleanup work, testing, environmental reports, lender requirements, or special circumstances.

No Loss Statement

If the operation has never experienced any pollution, environmental, tank, cleanup, or related liability claims, complete a No Loss Statement.

You do not need to email it to us. Once submitted, it will automatically notify the Kelly Insurance Group team.

No Claims? Complete No Loss Statement ➜

Current Loss Runs

If you currently have insurance coverage, we will need copies of your current carrier loss runs.

Use the button to review what loss runs are, how to request them, and copy email wording to send to your current carrier or agent.

Loss Run Instructions

Loss runs are a statistical history of your claim history. Most underwriters will require this information to provide a quote, even if you have had zero losses.

You may be able to retrieve your loss runs by logging into your online account with your current insurance company. Your claims history or loss runs may be available to download through the carrier portal.

If they are not available online, you can send an email to your current insurance company or your current servicing agent or broker.

Hi __________, We are currently reviewing our insurance program and we would like to have copies of our claims history, also known as Loss Runs, for our internal review. If you could provide this information for all lines we have on file with your company, that would be greatly appreciated. We are looking for our five-year Loss Run history. Thanks for your help and your quick attention to this matter.

Email wording copied.

Current Policy Documents

Please provide current copies of your existing insurance policy documents, if available. Pollution liability underwriters typically ask for these documents during underwriting.

Helpful documents may include current pollution liability policies, general liability policies, property policies, tank liability policies, umbrella/excess policies, endorsements, schedules, declarations pages, and any environmental coverage forms currently in place.

Upload in Step 5 Attach policy documents with your completed application and environmental supporting documents.

Upload Application & Environmental Documents

After completing and saving the Pollution Liability Insurance Application, upload it below. You may also upload current policy documents, declarations pages, endorsements, Phase I reports, Phase II reports, tank schedules, spill history, environmental studies, site plans, loss runs, lender requirements, permits, inspection documents, remediation reports, or other supporting information.

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Disclaimer: Coverage availability and eligibility may depend on many factors, including underwriting review, carrier guidelines, policy terms, state requirements, business operations, risk characteristics, and other information provided during the application or quoting process. Kelly Insurance Group cannot guarantee that every individual, customer, organization, or business seeking coverage will qualify for, receive, or successfully place insurance coverage. All policy coverages, exclusions, conditions, limits, endorsements, and terms should be carefully reviewed by the consumer, insured, or applicant to confirm that the coverage requested is the coverage being quoted, offered, or provided. Insurance coverage, policy changes, endorsements, cancellations, and other policy terms are not bound, changed, confirmed, or altered unless and until written confirmation is provided by a licensed Kelly Insurance Group team member, the applicable insurance carrier, or an authorized underwriter. This page is provided for general informational purposes only and does not provide legal advice, legal opinions, insurance coverage opinions, or policy interpretations. Information on this page should not be relied upon as a substitute for reviewing the actual policy language or consulting appropriate professional advisors. Kelly Insurance Group does not employ, supervise, or direct attorneys.