Application Form

Location

MW Capacity

MFG/ # of Panels

MFG/ # of Inverters

Year Installed

Operator Name

Please check coverages and limits desired

Submit Current Financial Statements

* Complete ACORD application or equivalent

List paid and pending losses over last 5 years for submitted coverages

Please detail annual energy generation by location

Annual KWH

Sold to

Are any site(s) planned or in the process of construction? If so, complete the following questions.

Submit a copy of the construction contract and design specifications.

Description

Values

Panels

Inverters

Power Tower

Operations Building

Balance of Plant

Spares

Business Income (1)

Total

(1) Attach a completed Power Generation Business Income worksheet for each location.

Coverage Extensions

*Limited capacity available in severe earthquake areas

Deductible

Additional underlying insurance information

Limits

Carrier

Premium

Auto

Number of Vehicles

Radius of Operations

Driver Selection/Training Criteria

International exposures:

I have read the above Application. I declare that to the best of my knowledge and belief the statements and information in this Application and any attachments thereto are true, accurate and complete. This information is given to the insurer for the specific purpose of obtaining insurance coverage. It is agreed that if any information given in this Application or in any attachments thereto is materially false, inaccurate or incomplete, the insurer may deny coverage or cancel the policy.

INFORMATION OR DATA CONTAINED IN OR SUBMITTED IN CONNECTION WITH THIS APPLICATION (OR OTHERWISE TO ANY OF THE MEMBER INSURERS OF CHUBB GROUP OF INSURANCE COMPANIES (“CHUBB”) IN CONNECTION WITH THE UNDERWRITING PROCESS) DOES NOT CONSTITUTE NOTICE OF AN OCCURRENCE, WRONGFUL ACT, CLAIM, SUIT OR OTHER CIRCUMSTANCE AND DOES NOT SATISFY ANY OF THE REPORTING NOTIFICATION OR OTHER PROVISIONS OF ANY POLICY. ALL SUCH NOTICES MUST BE GIVEN SEPARATELY IN ACCORDANCE WITH THE APPLICABLE POLICY CONDITIONS.

For the purpose of this application, the above-signed officer of all person(s) and entity(ies) proposed for this insurance declares and acknowledges by their signature above, that he/she has reviewed this application and the statements contained therein with his/her Chief Executive Officer, Chief Financial Officer, Chief Operating Officer or their equivalents, and that to the best of their knowledge and belief, after reasonable inquiry, the statements in this application, and in any attachments, are true and complete. Chubb is authorized to make any inquiry in connection with this application. Signing this application shall not constitute a binder or obligate Chubb to complete this insurance, but it is agreed this application shall be the basis upon which a policy may be issued. If the statements in this application or in any attachment change materially before the effective date of any proposed policy, the applicant must notify Chubb, and Chubb may modify or withdraw any quotation. You understand that the limit of liability under any policy to be issued in response hereto shall include both indemnity payments for claims and payment of claim and defense expenses, as defined in the policy.

NOTICE TO APPLICANT - PLEASE READ CAREFULLY

Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties, including but not limited to fines, denial of insurance benefits, civil damages, criminal prosecution and confinement in state prison.

Notice to Arkansas, Louisiana, New Mexico and West Virginia Applicants:

Notice to Arkansas, Louisiana, New Mexico and West Virginia Applicants:

Notice to California Applicants:

Notice to Colorado Applicants:

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Notice to District of Columbia Applicants:

“WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.”

Notice to Florida Applicants:

Any person who knowingly and with intent to injure, defraud, or deceive any insurer fi les a statement of claim or an application containing any false, incomplete, or misleading information, is guilty of a felony of the third degree.

Notice to Kentucky Applicants:

Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Notice to Maine Applicants:

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits.

Notice to Nebraska Applicants:

Any person who, knowingly and with intent to defraud any insurance company or other person, files an Application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent insurance act, which is a crime, where such person subsequently submits a claim.

Notice to New Jersey Applicants:

Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Notice to New York Applicants:

Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Notice to Ohio Applicants:

Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Notice to Oklahoma Applicants:

WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Notice to Oregon Applicants:

Any person, who knowingly and with intent to defraud any insurance company or other person, fi les an Application for insurance containing any false information, or conceals for the purpose of misleading information concerning any material fact thereto, may be guilty of an insurance fraud.

Notice to Pennsylvania Applicants:

Any person who knowingly and with intent to defraud any insurance company or other person fi les an application for insurance or statement of a claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Notice to Tennessee, Virginia and Washington Applicants:

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.