Environmental Liability (Including Mold) Claims Form

Your Policy Number is: W1BEB8220701 for the Policy Period: 07/01/22 to 06/30/23.

Today's Date(Required)

JIF:

School District(Required)

Contact Name(Required)

Contact Phone Number(Required)

Contact Email(Required)

When did the environmental condition occur, or was discovered?(Required)

Where did the environmental condition occur? Please include the street address:(Required)

Beazley Policy Number

Who should Beazley contact regarding this matter?

Business Administrator contact information (name, telephone, email):

Facilities Manager contact information (name, telephone, email):

Please describe the matter generally:

Has anyone threatened or asserted claims against your district? If so, please provide the name of the claimant(s), the date and circumstances of the claims or threats, and copies of any relevant documents.

Are there any other parties involved in this matter? If so, whom?

Are there any urgent concerns or needs to be addressed? If so, please explain:

School Pool for Excess Liability Limits

Joint Insurance Fund

Environmental Liability (Including Mold) Claims Form

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