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Contractors Pollution Liability · Loss Reporting

Spill or Pollution Incident Claim Form

Complete this form for any release, spill or discharge of a petroleum product, hazardous material, hazardous waste or other pollutant arising from your operations, whether at a job site, in transit, in storage or at your own premises. Fill in what you know; fields marked are required.

Use this form for pollution liability claims. Also have each witness fill out a Witness Statement. For a General Liability claim, use the GL claim form instead.

Claim reporting information

Gallagher Bassett, the claims administrator, needs this on every report.

GB Client Number042107
Client NameComeryx Insurance Services, Inc.

Client location

Incident

0 / 250

Involved party

The person or business affected, for example the property owner or claimant.

Claim contact

Who the adjuster should contact about this claim.
Type of spill or pollutant release
Was this spill or incident part of a vehicular accident?
Was this spill or incident located on property you own, rent or occupy?
Was this spill or incident located on a client’s or other third party’s property?
Was any person injured, or exposed to the released material?
Has any regulatory agency been notified or responded to the scene?
Named insured & policy information
Personnel involved in spill reportingSupervisor, safety contact, response contractor
Personnel involved in spill reporting

Job site supervisor / foreman

Company safety or environmental contact

Spill / incident response contractor

Details of spill or pollutant release
Location and conditions

If spill to water

If a ditch, culvert or storm drain, identify the water body the structure discharges to.
Actions taken
Reporting the spill
Was there a release of a reportable quantity, or a release to surface water, groundwater or a storm drain?

Report to Comeryx Claims. Report every spill or pollution incident to Comeryx Claims at claims@comeryx.com immediately. Report within 24 hours when the incident involves bodily injury, third-party property damage, emergency response, or significant third-party exposure. Emergency expenses incurred to respond to an imminent and substantial threat to public health, safety or the environment may be incurred without prior written consent provided they are reported to Comeryx within ten (10) days. Do not admit liability or agree to pay cleanup costs beyond emergency response without first consulting Comeryx Claims.

Regulatory reporting. Spills to water, or releases at or above a federal reportable quantity: immediately call the National Response Center at 1-800-424-8802 and the appropriate state environmental regulatory agency. Spills to soil, shallow groundwater, nearby creeks or storm drains, or explosive, flammable or toxic vapors that may be an immediate threat to health or the environment: call the appropriate state environmental regulatory agency and, where required, local emergency services.

Note: Project-specific permits, client contracts and local ordinances may impose additional or shorter reporting requirements. Keep a written log of every notification made.

Agencies contacted

Person responsible for managing termination / closure
Additional notes / information

Attach photographs, sketches, manifests and agency correspondence to your email.

Certification

The downloaded PDF includes a signature line if a signed copy is needed.