Environmental/Chemical Group Quote Form

Sirak-Moore Insurance Agency, Inc.

Environmental/Chemical Insurance Quote Form

For the fastest and most accurate insurance quote, please provide as much information as possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!

*Or if you prefer, fax your current declaration page to (330) 493-0642
Don't forget to put your daytime phone number on the fax. We'll get back to you right away.

Thanks for your inquiry.

Name of Insured: *

Contact Name: *

Contact Title:

Address:

Email address:

Daytime Phone:

Cell Phone:

Best time to reach you:

Website

Association Membership (NACD, SOCMA, ACC etc):

Length of time in business

Please Select

Business Activity
1. Broker/Drop Ship
2. Wholesale/Warehouse
3. Repackage/Relabel
4. Mixing/Blending
5. Manufacturing
6. Other

List the five (5) top products sold by volume:

	Product	Annual Volume
1.
2.
3.
4.
5.

Automobile

Do you haul your own products: Yes No

Average Trip Length: Within 50 Miles 50-200 Miles Over 200 Miles

Do you operate any tanker trucks or tanker trailers to transport chemical or
liquid products? Yes No

Pollution Liability Supplement

Facility Address: Total Acreage:

How long has present owner controlled or owned this property?

What structures are currently on this property (i.e. type of building, square footage, age, etc.)

List the current operations on this property:

Record

Please describe any pollution claims during the last five (5) years
(if none, please so state):

At the time of signing this Application, are you aware of any circumstances which may reasonably
be expected to give rise to a claim under the pollution liability, general liability, property or
automobile policy? Yes No

If yes, explain:

Comments or questions

* required information