Environmental Consultants and Contractors Application

Applicant: Date:
Address: 
City:           State:
Zip Code: Telephone:

Company is an (check one)
        individual:        partnership:        Corp:        JV:        Other:
        If "other" describe below:
       

 

1.       Coverage Requested:     New Business     Renewal         CGL     CPL     EIL     PL
2.       Proposed Effective Date:   Proposed Retroactive Date:  
3.       Limits of Liability/ Deductible:
  Limits requested:            Deductible Requested:  
 
4.       Other Coverages and Endorsements:  
5.       History of the Company:
  Date Established:  
  Have there been any acquisitions, consolidations, dissolution’s, mergers?   Yes     No
  If yes, explain
  Does the firm have: (check any or all)     Subsidiary     A Parent Company     Other related entities
  If yes, explain

 
6.       Prior Liability Carrier Information (fill in under each category):
  Coverage Form:       Carrier:        
  Receipts:       Limits:        
  Deductible:       Policy Type:        
  Rate:       Premium:        
         Any policy or coverage declined, cancelled or non-renewed during the prior three years?   Yes     No

  All Applicants must submit the following information in addition to the application:
1.)    Qualifications including resumes, brochures and a listing of previous projects.
2.)    Most recent income statements and balance sheet.
3.)    Five years of valued loss runs including pollution and professional, if applicable.
4.)    Completed Accord Application if CGL coverage is desired.
7.       Total personnel (List each person only once by primary function):
  a. Architects, engineers, geologists, hydrogeologists:
  b. Industrial Hygienists, toxicologists, CIH’s or CSPS:
  c. Draftsman Technicians:
  d. Supervisors/foreman/leadman:
  e. Laborers:
  f. AHERA, Hazpower:
  g. Other (specify)  

Please attach all key personnel resumes, certs and licenses.

8.       Has any officer of the company ever been the subject of disciplinary action by authorities as a result of a professional or contracting activities? Yes     No

9.       Enter the firm’s gross receipts. Please break down the receipts by scope of services:
  Scope of Services: Previous Year: Current Year: Projected:
  a.  
  b.  
  c.  
  d.  
  e.  
  f.  
  g.  
  h.  
  i.  
  j.  

10.     Subconsultants / subcontractors
  What % of your sales is associated with the use of subs:  
  Does your firm collect certificates of insurance from your subs? (check one) Yes    No
  Please identify the services that you subcontract:

11.     Do you use a standard indemnity contract with your clients and subs? (check one) Yes     No
  If no, please detail your contract procedures:

12.     Do you conduct tank installation work? (check one ) Yes     No
  If yes, please answer the following: % of overall sales associated with this operation:
Are the installed tanks precision tightness tested before being released to the owner?
(Check one) Yes     No
Do you apply any type of corrosion protection? Yes     No
Are tanks tested and certified by a registered professional before use? Yes     No

Please submit the following:    Resumes and certificates of all tank installation employees, type of tanks installed, type of corrosion protection you install, installation procedures.


13.     Do you install any type of liner, i.e. landfill, lagoons, etc. Yes     No

14.     Do you operate an in house lab? Yes     No    If yes, please answer the following:
Do you conduct regular in house training courses? Yes     No
If yes, how often?  
Are all lab employees properly certified and/or licensed? Yes     No

Please submit the following:    Lab accreditation certifications, table of contents of QA/QC manuals, and chemical hygiene plans.


15.     Do you conduct any geotechnical or geophysical operations? Yes     No    If yes, please answer the following:
% of overall sale associated with this operation?  

Please submit the following:    A detailed list of your geotechnical and geophysical operations detailed resumes of employees who conduct these operations.


16.     Do you conduct any Phase I or Real Estate Assessments? (check one) Yes     No    If yes, please answer the following:
% of sales associated with this operation:  
Do you follow ASTM –1527 guidelines? (check one) Yes     No
If no, attach a sample format.

17.     Has any claim, suit or notice of incident been made against the firm or ant staff member? Yes     No
If yes, please attach full details on each incident.

18.     Is the applicant aware of any circumstances which may result in any claim, suit of notice of incident against him, the firm, his predecessors in business, any of the present or past partners or officers, or any staff member? (check one) Yes     No
If yes, please attach full details on each incident.

 
    FRAUD WARNING: APPLICABLE TO ALL STATES
 
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 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

    WARRANTY STATEMENT
 
The undersigned authorized officer of the applicant declares that the statements set forth herein are true. The undersigned authorized officer agrees that if the information supplied on the application changes between the date of the application and the effective date of the insurance, he/she (undersigned) will immediately notify the insurer of such changes, and the insurer may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. Signing of this application does not bind the applicant to the insurer to complete the insurance.

Notice to 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 fact material thereto, commits a fraudulent insurance act, which is a crime.

   
   (Signature)

   
   (Title)

   
   (Date)