Environmental Small Consultants / Contractors APP SMALL ENVIRONMENTAL CONT CONSULT APP PDF Download Environmental Small Consultants / Contractors APP PGI Commercial APPLICATION FOR ENVIRONMENTAL CONSULTANTS AND CONTRACTORS 1. NAME OF APPLICANT:* Prefix First Last Suffix 2. MAILING ADDRESS:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*3. DATE ESTABLISHED* Date Format: MM slash DD slash YYYY *CorporationPartnershipIndividual4. During the past five years has the name of the firm been changed or has any other business been purchased or any merger of consolidation taken place?*YesNoIf yes, please give full details:5. Is the firm engaged in, owned by, associated with or controlled by any other business:*YesNoIf yes, give details:6. Coverages requested:Commercial General LiabilityYesNoContractors Pollution LiabilityYesNoProfessional LiabilityYesNoLimits of Liability requested:*Deductible:*7. Gross Revenues (Past three years):*Estimated for the next twelve (12) months:*Prior twelve (12) months:*Twelve (12) months prior:*8. TOTAL PERSONNEL:*a. Number of Principals:*b. Number of Engineers:*c. Number of Field Personnel:*d. Number of Supervisors:*e. Number of Architects:*f. Other (Describe)9. Have any of those listed in item 8 ever been the subject of disciplinary action by authorities as a result of their professional activities?*YesNoIf yes, please give details:10. Services Provided:Contracting ServicesConsulting ServicesEmergency Response% Gross RevenuesRemedial Investigations% Gross RevenuesUnderground Storage Tank Installation% Gross RevenuesRemedial Design% Gross RevenuesUnderground Storage Tank Removal% Gross RevenuesRemediation Oversight% Gross RevenuesGroundwater Remediation% Gross RevenuesHydrogeological Investigations% Gross RevenuesSoil Remediation% Gross RevenuesLab Testing/Analysis% Gross RevenuesDrilling% Gross RevenuesPhase I Environmental Assessments% Gross RevenuesSampling% Gross RevenuesPhase II/III Environmental Assessments% Gross RevenuesAsbestos/Lead abatement% Gross RevenuesRegulatory Compliance/Permitting% Gross RevenuesMold Abatement% Gross RevenuesIndustrial Hygiene% Gross RevenuesFire & Water Response% Gross RevenuesTraining% Gross RevenuesIndustrial Cleaning% Gross RevenuesWaste Brokering% Gross RevenuesTank/Pipe Cleaning% Gross RevenuesMold Consulting% Gross RevenuesMobile Incineration% Gross RevenuesAir monitoring% Gross RevenuesOther (Describe Below)Other (Describe Below)11. Has the Applicant ever provided any service other that noted under Question 10?YesNoIf “Yes”, please explain:12. Does the Applicant’s practice involve any subletting or subcontracting of work to others?YesNoIf yes, please specify what is sublet or subcontracted:a. Subletting of work/subcontracting to others%b. Is evidence of Insurance from subcontractors/consultants required?YesNo13. Foreign Work?YesNoIf Yes, please give full details:14. Please indicate the approximate percentage of work under each heading:Residential:Commercial:Industrial:Governmental:Other (Describe):15. Does any one contract or client represent more than 50% of annual work?YesNoIf yes, please give details:16. Does the Applicant work with other firms in Joint Ventures?YesNoProvide complete details:17. Give Insurance coverage details for last five years for the firm:CarrierPremiumLimitDeductiblePolicy TermRetroactive Date Commercial General Liability (Please use the + button to the right to add additional rows.) CarrierPremiumLimitDeductiblePolicy TermRetroactive Date Pollution/Professional Liability (Please use the + button to the right to add additional rows.) 18. Please provide the following additional information as an attachment to this application:a. Past five years loss runs (if applicable):b. Resumes of key personnel:c. Most recent annual income statement and balance sheet:d. Expiring declarations pages evidencing retroactive dates:19. Has any application for Commercial General Liability, Pollution Liability or Professional Liability Insurance made on behalf of the firm, any predecessors in business or present Partners ever been declined or has the insurance ever been cancelled or renewal refused?YesNoIf yes, please give details:20. Has any claim ever been made against the firm or any persons named in item 1. or in item 6.b.(ii)?YesNoIf yes, please attach details stating: 1) date when claim was made; 2) date the act giving rise to the claim was committed; 3) name of the claimant; 4) nature of the claim; 5) amount involved including reserves; and 6) final disposition:21. Is the Applicant aware of any circumstances which may result in any claim against him, the firm, his predecessors in business, or any of the present or past Partners or Officers?YesNoIf yes, please give full details on the same basis as item 20.22. Has any insurer cancelled or refused to renew any similar insurance during the past five years?YesNo23. The applicant declares that the above statements and representations are true and correct and that no facts have been suppressed or misstated. The completion of this application does not bind the Company to sell nor the applicant to purchase this insurance, but any subsequent contract issued will be in full reliance upon the statements and representations made in this application and this application will be made a part of the policy. Signature of Applicant:*Type Name:*Title:*Date:* Date Format: MM slash DD slash YYYY Producer Name:*Retail Agency Name:* This iframe contains the logic required to handle Ajax powered Gravity Forms.