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 State ZIP Code
Phone Number*
3. DATE ESTABLISHED*
*
- Corporation
- Partnership
- Individual
4. 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?*
- Yes
- No
If yes, please give full details:
5. Is the firm engaged in, owned by, associated with or controlled by any other business:*
- Yes
- No
If yes, give details:
6. Coverages requested:
Commercial General Liability
- Yes
- No
Contractors Pollution Liability
- Yes
- No
Professional Liability
- Yes
- No
Limits 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?*
- Yes
- No
If yes, please give details:
10. Services Provided:
Contracting Services
Consulting Services
Emergency Response
% Gross Revenues
Remedial Investigations
% Gross Revenues
Underground Storage Tank Installation
% Gross Revenues
Remedial Design
% Gross Revenues
Underground Storage Tank Removal
% Gross Revenues
Remediation Oversight
% Gross Revenues
Groundwater Remediation
% Gross Revenues
Hydrogeological Investigations
% Gross Revenues
Soil Remediation
% Gross Revenues
Lab Testing/Analysis
% Gross Revenues
Drilling
% Gross Revenues
Phase I Environmental Assessments
% Gross Revenues
Sampling
% Gross Revenues
Phase II/III Environmental Assessments
% Gross Revenues
Asbestos/Lead abatement
% Gross Revenues
Regulatory Compliance/Permitting
% Gross Revenues
Mold Abatement
% Gross Revenues
Industrial Hygiene
% Gross Revenues
Fire & Water Response
% Gross Revenues
Training
% Gross Revenues
Industrial Cleaning
% Gross Revenues
Waste Brokering
% Gross Revenues
Tank/Pipe Cleaning
% Gross Revenues
Mold Consulting
% Gross Revenues
Mobile Incineration
% Gross Revenues
Air monitoring
% Gross Revenues
Other (Describe Below)
Other (Describe Below)
11. Has the Applicant ever provided any service other that noted under Question 10?
- Yes
- No
If “Yes”, please explain:
12. Does the Applicant’s practice involve any subletting or subcontracting of work to others?
- Yes
- No
If yes, please specify what is sublet or subcontracted:
a. Subletting of work/subcontracting to others
%
b. Is evidence of Insurance from subcontractors/consultants required?
- Yes
- No
13. Foreign Work?
- Yes
- No
If 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?
- Yes
- No
If yes, please give details:
16. Does the Applicant work with other firms in Joint Ventures?
- Yes
- No
Provide complete details:
17. Give Insurance coverage details for last five years for the firm:
Carrier Premium Limit Deductible Policy Term Retroactive Date

Commercial General Liability (Please use the + button to the right to add additional rows.)
Carrier Premium Limit Deductible Policy Term Retroactive 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?
- Yes
- No
If 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)?
- Yes
- No
If 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?
- Yes
- No
If 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?
- Yes
- No
23. 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:*
Producer Name:*
Retail Agency Name:*

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Carrier	Premium	Limit	Deductible	Policy Term	Retroactive Date

Carrier	Premium	Limit	Deductible	Policy Term	Retroactive Date

Environmental Small Consultants / Contractors APP

Environmental Small Consultants / Contractors APP

PGI Commercial

APPLICATION FOR ENVIRONMENTAL CONSULTANTS AND CONTRACTORS