POLLUTION LEGAL LIABILITY INSURANCE CLAIM

PART I: CLAIM IDENTIFICATION

A. Policy Information

Insurance Company: [________________________________]
Policy Number: [________________________________]
Policy Period: [__/__/____] to [__/__/____]
Policy Type:
☐ Pollution Legal Liability (PLL)
☐ Environmental Impairment Liability (EIL)
☐ Premises Pollution Liability (PPL)
☐ Contractors Pollution Liability (CPL)
☐ Site-Specific Environmental Policy
☐ Cost Cap/Remediation Cost Containment
☐ Combined Environmental Policy
☐ Other: [________________________________]

Claim Number (if assigned): [________________________________]

B. Named Insured Information

Named Insured: [________________________________]
Address:
Street: [________________________________]
City: [________________________________]
State: [____] ZIP Code: [__________]

Contact Person:
Name: [________________________________]
Title: [________________________________]
Phone: [________________________________]
Email: [________________________________]

C. Broker/Agent Information

Broker/Agent Name: [________________________________]
Company: [________________________________]
Phone: [________________________________]
Email: [________________________________]

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PART II: NOTICE OF CLAIM

THIS IS A NOTICE OF CLAIM UNDER THE ABOVE-REFERENCED POLICY

Date of Notice: [__/__/____]

A. Claim Type

☐ First-Party Claim (Cleanup costs incurred by insured)
☐ Third-Party Claim (Bodily injury/property damage claim by third party)
☐ Government Enforcement Action (EPA, state agency, etc.)
☐ Cost Cap/Cost Overrun Claim
☐ Combination of Above

B. Date(s) of Discovery

Date Pollution Condition Discovered: [__/__/____]
Date Claim/Demand Received (if third-party): [__/__/____]
Date Enforcement Action Received (if government): [__/__/____]

How Was the Pollution Condition Discovered:
☐ Routine Environmental Monitoring
☐ Environmental Site Assessment (Phase I/Phase II)
☐ Government Inspection
☐ Third-Party Complaint
☐ Accidental Release/Spill
☐ Soil/Groundwater Testing
☐ Vapor Intrusion Investigation
☐ Employee Report
☐ Other: [________________________________]

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PART III: POLLUTION CONDITION DESCRIPTION

A. Location of Pollution Condition

Site/Facility Name: [________________________________]

Site Address:
Street: [________________________________]
City: [________________________________]
State: [____] ZIP Code: [__________]
County: [________________________________]

Site Coordinates (if known):
Latitude: [________________________________]
Longitude: [________________________________]

Is This a Scheduled Location Under the Policy: ☐ Yes ☐ No

B. Description of Pollution Condition

Type of Contamination:
☐ Soil Contamination
☐ Groundwater Contamination
☐ Surface Water Contamination
☐ Sediment Contamination
☐ Vapor Intrusion
☐ Indoor Air Contamination
☐ Other: [________________________________]

Contaminants/Pollutants Identified:

Contaminant	Concentration	Medium	Regulatory Standard
[________________________________]	[________________]	☐ Soil ☐ GW ☐ Air	[________________]
[________________________________]	[________________]	☐ Soil ☐ GW ☐ Air	[________________]
[________________________________]	[________________]	☐ Soil ☐ GW ☐ Air	[________________]
[________________________________]	[________________]	☐ Soil ☐ GW ☐ Air	[________________]

PFAS Contamination (if applicable):
☐ PFOA Detected
☐ PFOS Detected
☐ Other PFAS: [________________________________]

Estimated Extent of Contamination:
Area Affected: [________________________________] square feet/acres
Depth of Soil Contamination: [________________________________] feet
Groundwater Plume Size: [________________________________] square feet
Plume Migration: ☐ On-Site Only ☐ Off-Site Migration

C. Source and Cause of Pollution Condition

Known or Suspected Source:
☐ Underground Storage Tank (UST)
☐ Aboveground Storage Tank (AST)
☐ Historical Operations
☐ Waste Disposal Area
☐ Spill/Release Incident
☐ Third-Party Migration
☐ Unknown
☐ Other: [________________________________]

Date of Release (if known): [__/__/____]
Duration of Release (if known): [________________________________]

Detailed Description of Source and Cause:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

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PART IV: THIRD-PARTY CLAIMS (If Applicable)

A. Claimant Information

Claimant 1:
Name: [________________________________]
Address: [________________________________]
Phone: [________________________________]
Attorney (if represented): [________________________________]

Nature of Claim:
☐ Bodily Injury
☐ Property Damage
☐ Diminution in Property Value
☐ Medical Monitoring
☐ Other: [________________________________]

Claimed Damages: $[________________]
Date Claim Received: [__/__/____]

[Add additional claimants as needed]

B. Litigation Status

Lawsuit Filed: ☐ Yes ☐ No

If Yes:
Case Name: [________________________________]
Court: [________________________________]
Case Number: [________________________________]
Date Filed: [__/__/____]

Complaint Attached: ☐ Yes ☐ No

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PART V: GOVERNMENT ENFORCEMENT ACTION (If Applicable)

A. Agency Information

Issuing Agency:
☐ EPA Region [____]
☐ State Environmental Agency: [________________________________]
☐ Local Agency: [________________________________]
☐ Other: [________________________________]

Contact Person:
Name: [________________________________]
Title: [________________________________]
Phone: [________________________________]
Email: [________________________________]

B. Enforcement Action Details

Type of Action:
☐ Notice of Violation (NOV)
☐ Administrative Order
☐ Consent Order/Agreement
☐ Unilateral Administrative Order (UAO)
☐ CERCLA § 104(e) Information Request
☐ PRP Notification Letter
☐ Civil Complaint
☐ Other: [________________________________]

Date of Action: [__/__/____]
Response Deadline: [__/__/____]

Statutory/Regulatory Basis:
☐ CERCLA
☐ RCRA
☐ Clean Water Act
☐ State Superfund
☐ UST Program
☐ Other: [________________________________]

Relief Sought:
☐ Investigation
☐ Remediation
☐ Civil Penalties: $[________________]
☐ Cost Recovery: $[________________]
☐ Natural Resource Damages: $[________________]
☐ Injunctive Relief
☐ Other: [________________________________]

Copy of Enforcement Action Attached: ☐ Yes ☐ No

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PART VI: COSTS INCURRED AND ESTIMATED

A. Costs Incurred to Date

Category	Amount	Date(s) Incurred	Vendor/Provider
Site Investigation	$[________________]	[________________]	[________________________________]
Remediation	$[________________]	[________________]	[________________________________]
Legal Defense	$[________________]	[________________]	[________________________________]
Regulatory Compliance	$[________________]	[________________]	[________________________________]
Business Interruption	$[________________]	[________________]	N/A
Third-Party Property Damage	$[________________]	[________________]	[________________________________]
Emergency Response	$[________________]	[________________]	[________________________________]
Other: [____________]	$[________________]	[________________]	[________________________________]
TOTAL INCURRED	$[________________]

B. Estimated Future Costs

Category	Estimated Amount	Basis for Estimate
Additional Investigation	$[________________]	[________________________________]
Remediation	$[________________]	[________________________________]
Long-term Monitoring	$[________________]	[________________________________]
Legal Defense	$[________________]	[________________________________]
Regulatory Compliance	$[________________]	[________________________________]
Third-Party Claims	$[________________]	[________________________________]
Other: [____________]	$[________________]	[________________________________]
TOTAL ESTIMATED	$[________________]

C. Total Claim Amount

Total Costs Incurred: $[________________]
Total Estimated Future Costs: $[________________]
Total Claim Amount: $[________________]

Policy Limit: $[________________]
Self-Insured Retention/Deductible: $[________________]

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PART VII: POLICY COVERAGE ANALYSIS

A. Relevant Policy Provisions

Coverage Section(s) Implicated:
☐ Coverage A - Cleanup Costs
☐ Coverage B - Third-Party Bodily Injury/Property Damage
☐ Coverage C - Legal Defense Costs
☐ Coverage D - Business Interruption
☐ Coverage E - Emergency Response
☐ Other: [________________________________]

B. Coverage Triggers

Triggering Event:
☐ Claims-Made Trigger (date claim first made)
☐ Occurrence Trigger (date of pollution event)
☐ Discovery Trigger (date pollution first discovered)
☐ Manifestation Trigger (date damage manifested)

Date of Triggering Event: [__/__/____]
Within Policy Period: ☐ Yes ☐ No ☐ Uncertain

C. Potential Coverage Issues

Identify any known coverage issues:
☐ Prior Knowledge
☐ Late Notice
☐ Pre-Existing Contamination
☐ Pollution Exclusion in Primary Policy
☐ Intentional Act
☐ Known Loss
☐ Policy Period Issues
☐ Scheduled Site Issues
☐ Other: [________________________________]

Explanation:
[________________________________]
[________________________________]

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PART VIII: SUPPORTING DOCUMENTATION

A. Documents Attached to This Claim

☐ Copy of Insurance Policy (or relevant sections)
☐ Environmental Site Assessment Reports (Phase I, Phase II)
☐ Laboratory Analytical Results
☐ Remediation Work Plans
☐ Regulatory Correspondence
☐ Enforcement Action Documents
☐ Third-Party Demand Letters/Complaints
☐ Invoices for Costs Incurred
☐ Expert Reports
☐ Photographs/Site Maps
☐ Historical Documents
☐ Prior Insurance Policies (for occurrence claims)
☐ Other: [________________________________]

B. Documents to Be Provided

Document	Expected Date	Status
[________________________________]	[__/__/____]	☐ Pending ☐ Requested
[________________________________]	[__/__/____]	☐ Pending ☐ Requested
[________________________________]	[__/__/____]	☐ Pending ☐ Requested

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PART IX: RESERVATION OF RIGHTS

Insured's Reservation:

The insured reserves all rights under the policy and applicable law, including but not limited to:

1. The right to amend or supplement this claim;
2. The right to assert additional policy coverages;
3. The right to recover all amounts covered under the policy;
4. The right to dispute any coverage determination; and
5. All other rights and remedies available at law or in equity.

This notice is provided in good faith based on information presently available. The insured reserves the right to provide additional information as it becomes available and to modify the claim accordingly.

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PART X: COOPERATION ACKNOWLEDGMENT

The insured acknowledges its duty to cooperate with the insurer in the investigation and adjustment of this claim, including:

☐ Providing access to relevant documents and information
☐ Making personnel available for interviews
☐ Assisting in the investigation of the claim
☐ Cooperating in the defense of third-party claims
☐ Complying with reasonable requests from the insurer

The insured requests that the insurer:

☐ Acknowledge receipt of this claim within [____] business days
☐ Assign a claim adjuster and provide contact information
☐ Advise of any coverage determination or reservation of rights
☐ Approve defense counsel and retain qualified experts
☐ Provide regular updates on claim status

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PART XI: CERTIFICATION

I certify that the information provided in this claim is true and accurate to the best of my knowledge. I understand that providing false or misleading information may result in denial of coverage and other legal consequences.

Signature: [________________________________]
Printed Name: [________________________________]
Title: [________________________________]
Company: [________________________________]
Date: [__/__/____]

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PART XII: SUBMISSION INSTRUCTIONS

Submit this claim to:

Claims Department:
[Insurance Company Name]
[Address]
[City, State ZIP]

Phone: [________________________________]
Fax: [________________________________]
Email: [________________________________]

Copy to Broker:
[Broker Name]
[Address]
[City, State ZIP]

Copy to Legal Counsel:
[Attorney Name]
[Firm]
[Address]

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STATE-SPECIFIC NOTES

California

• California Insurance Code governs claims handling practices
• Strict bad faith exposure for improper claims handling
• California Fair Claims Settlement Practices Regulations (10 CCR § 2695)
• Notice provisions strictly enforced
• Insurer must respond to claim within 40 days

Texas

• Texas Insurance Code Chapter 541 (Unfair Settlement Practices)
• Texas Prompt Payment of Claims Act
• Texas Department of Insurance regulates claims practices
• 15-day acknowledgment requirement for claims
• 15-day response requirement after investigation complete

Florida

• Florida Statutes § 627.426 (Claims Administration)
• Bad faith exposure under F.S. § 624.155
• 14-day acknowledgment requirement
• 30-day payment or denial requirement
• Civil Remedy Notice required before bad faith suit

New York

• NY Insurance Law Article 24 (Unfair Claims Practices)
• NY Regulation 64 (Claims Handling)
• 15-day acknowledgment requirement
• Prompt investigation and determination required
• Superintendent of Financial Services oversight

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CLAIM TRACKING LOG

Date	Activity	Contact	Notes
[__/__/____]	Claim Submitted	[________________]	[________________________________]
[__/__/____]	Acknowledgment Received	[________________]	[________________________________]
[__/__/____]	Adjuster Assigned	[________________]	[________________________________]
[__/__/____]	[________________]	[________________]	[________________________________]
[__/__/____]	[________________]	[________________]	[________________________________]

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SOURCES AND REFERENCES

• Insurance policy terms and conditions
• State insurance regulations
• NAIC Environmental Insurance Resources: https://content.naic.org/insurance-topics/environmental-insurance
• EPA CERCLA and RCRA guidance documents
• State environmental agency cleanup requirements

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This template is provided for general informational purposes. Pollution liability insurance claims are complex and policy-specific. Always review your specific policy terms, comply with all notice requirements, and consult with qualified insurance coverage counsel when submitting a claim.