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Contractors Operations and Professional Services
(COPS) Proposal
American Home Assurance Company
Notice: The COPS policy provides that the limit of liability available to pay settlements or cleanup
costs shall be reduced by amounts incurred for legal defense. Further note that amounts incurred for
legal defense shall be applied against the deductible amount.
Instructions
1. Please complete all of this application. Your application may not be dealt with if this form is
incomplete and/or required submission information is absent.
2. If space is insufficient to complete answers, please continue on your firm's letterhead.
3. Have this form signed and dated by an owner, partner or director/officer of your firm.
4. See page 8 for list(s) of required submission information.
Applicant’s Details
1. Named Insured/Name of Company__________________________________________________
Address of Head Office ___________________________________________________________
Website ______________________________________________________________________
Contact and Title _______________________________________________________________
ABN Number __________________________________________________________________
Input Tax Credit percentage _______________________________________________________
Named Insured is a Partnership Corporation Joint Venture Other
2. Attach a list of proposed Named Insureds to be covered by this policy (only those entities
performing the services and/or operations as proposed will be designated as Named Insureds).
3. Check coverage(s) you are applying for:
A Contractor's Operations and Professional Services (COPS)
Limit of liability______________________________________________________________
SIR/Deductible _____________________________________________________________
Proposed Effective Date ______________________________________________________
4. How long has the Named Insured been in business? ____________________________________
5. During the past five years has the name of the applicant been changed or has any other
business been purchased or have any mergers or consolidations taken place?
Yes No, If “yes”, please describe.
_____________________________________________________________________________
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6. Total Professional Staff of Applicant
(1) Principals _________________________________________________________________
(2) Supervisors / Foreman _______________________________________________________
(3) Total number of engineers & architects ___________________________________________
(4) Total number of field personnel _________________________________________________
(5) Hydrgeologists, Geologists, Chemists ____________________________________________
(6) All other (describe) __________________________________________________________
7. Are any Joint Ventures being proposed for coverage under this policy?
Yes No, If “yes”, please describe.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
8. Are your projects bonded?
Yes No, If “yes”, please describe.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
9. Does any one project or contract represent more than 25% of annual fees?
Yes No, If “yes”, please describe.
_____________________________________________________________________________
_____________________________________________________________________________
10. Please list the combined prior year's revenue.
_____________________________________________________________________________
_____________________________________________________________________________
11. Contract Values
Estimate for next 12 months Present 12 months Previous 12 months
From ......................... ......................... .........................
To ......................... ......................... .........................
All Operations $ $ $
Construction only no design $ $ $
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Profile of Operations
12. Please complete the following for projected sales over the next 12 months.
A. PROFESSIONAL SERVICES
A1 Environmental Services
(a) (b) (c) (d)
% In house % Sub-contracted out Projected $ sales Number of jobs
Decommissioning and Demolition
Remedial Investigations
Feasibility Studies
Remedial Design Plans and Specs
Obvs/Inspect of Construction
Const/Proj Management
Real Estate Audits
Soil Testing/Analysis
Surveying
Lab Testing/Analysis
Asbestos/Lead/Mold Abatement Design
EnvRisk Assessments/Audits/Indoor Air
Quality Asses
Regulatory Consulting/Permitting
Tank Testing/Maintainance
Tank System Design
Waste Brokering/Rec/Arrange
Health & Safety Training
Other (please explain)
Total Section A1 X X
A2 Non-Environmental Services
(a) (b) (c) (d)
% In house % Sub-contracted out Projected $ sales Number of jobs
Feasibilty Studies
Constuct/Proj Management
Surveying
Design Other Than....
Waste Water/Sewer Design
Potable Water System Design
Other Process/Engineering
Geotechnical/Foundations/Soils
HVAC/Electrical/Mechanical Eng
Civil/Structural Engineering
Lab Testing
Construction Materials Testing
Other (please explain)
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Total Section A2
A3 Other Services
(a) (b) (c) (d)
% In house % Sub-contracted out Projected $ sales Number of jobs
Product Design (products for sale)
Software Design/Programming
Financial Management/Consulting
Other (please explain)
Total Section A3 X X
Total Section A2 X X
Total Section A1 X X
TOTAL SECTION A X X
B. REMEDIAL ACTION CONTRACTING OPERATIONS
B1 Environmental Contracting
(a) (b) (c) (d)
% In house % Sub-contracted out Projected $ sales Number of jobs
Groundwater Sampling
Soil Sampling
Haz Material Cleanup/soil excavation
Groundwater Treatment & Recovery
Waste Storage
On-Site Haz Waste Treatment
Mobile Incineration
Barrier/Liner Contractors
Emergency Haz Material Cleanup
Tank Removal/Installation
PCB Oil/Equip Retrofill & Removal
Hydrocar./Chem. Recycling/recovery
Dredging
Asbestos/Lead Abatement
Mold Abatement
Other (please explain)
Total Section B1
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B2 Non-Environmental Contracting
(a) (b) (c) (d)
% In house % Sub-contracted out Projected $ sales Number of jobs
Carpentry, Framing
Construction Management
Demolition/Dismantling
Drilling
Electrical
Excavation/Grading
General Contracting
HVAC/Mechanical
Industrial Cleaning (incl. sewer/septic)
Insulation
Logging
Masonry, concrete
Marine
Oil Lease
Painting
Pipeline
Plumbing
Roofing (no residential)
Steel Erection
Street and Road
Other (please explain)
Total Section B2
Total Section B1
TOTAL SECTION B
Section Projected $ sales Number of jobs
Professional Services
Remedial Action Contracting Operations
Grand Total
13. Detail general radius of foreign operations (i.e. Country(ies)) where operations normally occur.
Indicate percentage relative to total projected values under question 10.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
14. Please detail the percentage of work for overseas work and the percentage of work performed in
each state, based on percentage of fee income as noted under question 10.
NSW________% VIC_______% SA________% WA________% TAS________%
NT________% ACT________% QLD________% Overseas________%
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15. Does your company select or arrange for the site of disposal for hazardous or non hazardous
waste on behalf of clients?
Yes No
16. Does your company own, operate or lease licensed waste treatment, storage or disposal
facilities?
Yes No
17. Do you ever rent/lease out equipment?
Yes No, If “yes”, please describe.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
18. Are updated certificates of insurance from subcontractors kept on file?
Yes No
19. Are these certificates required to show pollution liability insurance?
Yes No
If “yes”, indicate percentage ____________ %
20. What are the minimum limits of liability you require for your subcontractors?
(a) General Liability ____________________________________________________________
(b) Pollution Liability ____________________________________________________________
(c) Professional Liability _________________________________________________________
21. Do you require subcontractors policies to name you as an additional insured?
Yes No
If “yes”, indicate percentage ____________ %
22. Do your contracts with subcontractors contain an indemnification provision?
Yes No
If “yes”, attach copies of all insurance requirements and indemnification clauses.
If “yes”, indicate percentage ____________ %
23. Does your company enter into written contracts where you assume liability?
Yes No
If yes, attach copies of all insurance requirements and indemnification clauses.
If “yes”, indicate percentage ____________ %
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24. Please list your current liability coverage information.
Coverage Carrier Limits Expiration SIR Retrodate
General Liability
Contractors
Pollution
Liability
Workers Comp
Umbrella
Auto Liability
Errors and
Omissions
25. Do you ever make use of casual labour?
Yes No, If “yes”, please describe.
_____________________________________________________________________________
27. Please list any raw or process materials used at the jobsite (include all gasoline, kerosene, diesel
fuel usage).
Description of material Quantity stored on job site Method of storage
(Drum / Tank)
The following two questions must be answered for all coverages.
28. Have any claims been previously made against the applicant or reported under any other
Pollution or Professional Liability policies?
Yes No
If “yes”, state:
(a) the date when claim was made _________________________________________________
(b) the date the incident, act or omission giving rise to the claim took place __________________
(c) name of the claimant _________________________________________________________
(d) nature of the claim___________________________________________________________
(e) amount paid or estimated may be paid ___________________________________________
(f) final disposition or current status ________________________________________________
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It is agreed that claims made prior to the inception of the policy period are excluded from this
proposed coverage, unless expressely provided otherwise in the policy or by endorsement.
Initial Yes
29. Is the applicant aware of any fact, circumstance or situation which could result in a claim being
made against it or any other person or entity for whom coverage will be sought?
Yes No, If “yes”, please describe.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Safety
30. Are personnel trained in the use of personal protective equipment?
Yes No
31. Does your company conduct on a regular basis the following seminars?
(a) Occupational Health and Safety Yes No
(b) Management and Safety Regulations Yes No
Submission Required Information
32. The following information is required for all policies and should be supplied at the time of
submitting application:
Brochure/statement of qualification
Safety Procedure/Manual
Resumes of Key Personnel including all Project Managers
Project list (to include brief description and contract value)
Standard terms of Engagement
Hard copy of loss runs applicable to these coverages including pollution loss information.
Audited financial statements (last 2 years) and current interim financial (may be unaudited)
33. The following information is required for CPL coverage.
Spill or Emergency Contingency Plans
Training Manual
Standard Operating Procedures, if available
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PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN BELOW WHERE INDICATED. IF A POLICY IS
ISSUED THIS SIGNED STATEMENT WILL BE ATTACHED TO THE POLICY.
THE INSURED HEREBY ACKNOWLEDGES THAT HE/SHE/IT IS AWARE THAT THE LIMIT OF LIABILITY CONTAINED IN
THE CPL POLICY SHALL BE REDUCED, AND MAY BE COMPLETELY EXHAUSTED, BY THE COSTS OF LEGAL
DEFENSE AND, IN SUCH EVENT, THE INSURER SHALL NOT BE LIABLE FOR THE COSTS OF LEGAL DEFENSE OR FOR
THE AMOUNT OF ANY JUDGMENT OR SETTLEMENT OR CLEANUP COSTS TO THE EXTENT THAT SUCH EXCEEDS THE
LIMIT OF LIABILITY OF THIS POLICY.
THE INSURED HEREBY FURTHER ACKNOWLEDGES THAT HE/SHE/IT IS AWARE THAT LEGAL DEFENSE COSTS THAT
ARE INCURRED SHALL BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT.
Declaration
The applicant represents that the above statements and facts are true and that no material facts have
been suppressed or misstated.
Completion of this form does not bind coverage. Applicant's acceptance of Insurer's quotation and
Insurer's written agreement to be bound is required to bind coverage and to issue policy. It is agreed
that this form shall be the basis of the contract should a policy be issued, and will be attached to the
policy.
All written statements and materials furnished to the Insurer in conjunction with this application are
hereby incorporated by reference into this application and made apart hereof.
If an order is received, the application is attached to the policy so it is necessary that all questions be
answered in detail.
Signed ....................................................
Title .........................................................
(to be signed by Chairman/Chief Executive or equivalent)
Company ..................................................
Date ........................................................
Important Notices
The COPS policy has a claims-made basis for professional indemnity coverage. The Contractors Pollution
Liability policy can be provided on a claims-made basis or on an occurrence basis. Please note the following
claims-made notice if you choose the Contractors Pollution Liability Claims Made policy.
Claims-Made Insurance
This policy is issued by American Home Assurance Company on a claims-made and notified basis. This means
that this policy only covers Claims (as defined) first made against you (the Insured) during the Policy Period (as
defined) and notified to the insurer in writing during the Policy Period. This policy does not provide cover for any
Claims made against you (the Insured) during the Policy Period if at any time prior to the commencement of the
Policy Period you (the Insured) became aware of facts which might give rise to those Claims being made
against you (the Insured), or if the Pollution Conditions which gave rise to the Claim against you existed before
the Retroactive Date specified in the Schedule.
Section 40(3) of the Insurance Contracts Act 1984 provides that where you (the Insured) gave notic e in writing to
the insurer of facts that might give rise to a Claim against you (the Insured) as soon as was reasonably
practicable after you (the Insured) became aware of those facts but during the Policy Period, the insurer cannot
refuse to pay a Claim which arises out of those facts, when made, because it was made after the Policy Period
COPS PROP AUSTRALIA 9 of 10
had expired. Please note that the Insured may do nothing after a Claim to waive or prejudice its rights to which
the insurer expects to be subrogated.
Insured’s Duty of Disclosure
Section 21 of the Insurance Contracts Act 1984 (Cth) provides that before you enter into a contract of General
Insurance with an insurer, you have a duty to disclose to the insurer every matter that is known to you and which
you know, or a reasonable person in the circumstances could be expected to know, is relevant to the insurer’s
decision whether to accept the risk of the insurance and, if so, upon what terms. You have the same duty to
disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance.
However, your duty of disclosure does not require you to disclose matters:
that diminish the risk to be undertaken by the insurer;
that are of common knowledge;
that your insurer knows or, in the ordinary course of its business, ought to know;
as to which compliance with your duty is waived by the insurer.
This duty of disclosure continues after the proposal form has been completed up until the Policy Period
commences.
Consequences of Non-Disclosure
If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the
contract in respect of a Claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may
also have the option of avoiding the contract from its beginning.
Duty of Utmost Good Faith
The duty of utmost good faith applies to this contract. This means that there is implied into this contract a
provision requiring each party to it to act towards the other party, in respect of any matter arising under or in
relation to it, with the utmost good faith.
American Home Assurance Company
ABN: 67 007 483 267
COPS PROP AUSTRALIA 10 of 10
