Fillable ENGINEERS, CONSULTANTS, TESTING FIRMS & LABORATORIES APPLICATION (Risk Placement Services, Inc.)

Fill Online, Printable, Fillable, Blank ENGINEERS, CONSULTANTS, TESTING FIRMS & LABORATORIES APPLICATION (Risk Placement Services, Inc.) Form

Use Fill to complete blank online RISK PLACEMENT SERVICES, INC. pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

ENGINEERS, CONSULTANTS, TESTING FIRMS & LABORATORIES APPLICATION (Risk Placement Services, Inc.)

On average this form takes 65 minutes to complete

The ENGINEERS, CONSULTANTS, TESTING FIRMS & LABORATORIES APPLICATION (Risk Placement Services, Inc.) form is 7 pages long and contains:

  • 1 signature
  • 29 check-boxes
  • 241 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Risk Placement Services, Inc. forms online.

BROWSE RISK PLACEMENT SERVICES, INC. FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FEI-APP 08 08 Page 1 of 7
ENGINEERS, CONSULTANTS, TESTING FIRMS & LABORATORIES
APPLICATION
APPLICANT DATE
ADDRESS
CITY STATE ZIP
TELEPHONE WEB ADDRESS
Applicant is an:
INDIVIDUAL PARTNERSHIP CORPORATION JOINT VENTURE OTHER
PLEASE SUBMIT THE FOLLOWING INFORMATION IN ADDITION TO THIS APPLICATION:
1) Statement of Qualifications (SOQ) including resumes.
2) Most recent income statement and balance sheet.
3) Three years of currently valued loss runs.
4) Project Descriptions – Supplemental Page or Form 254.
COVERAGE
REQUESTED:
New Business Renewal Business
PROPOSED EFFECTIVE DATE:
LIMITS OF LIABILITY & DEDUCTIBLE
Limits Requested:
Deductible Requested:
COMMERCIAL GENERAL LIABILITY
Retroactive date
__/__/__
CONTRACTOR’S POLLUTION LIABILITY
Retroactive date
__/__/__
PROFESSIONAL LIABILITY
Retroactive date
__/__/__
Applicant’s History
Date Established:
1. Have there been any mergers, acquisitions, consolidations or
dissolution? If yes, explain:
Yes No
2. Does the firm have: Subsidiaries Parent Company Other Related Entities
(If yes, explain):
3. Do you share employees (if yes, explain)?
Yes No
Prior Liability Carrier Information
Commercial General Liability Contractors Pollution Liability Professional Liability
None: ________________________ None: ________________________ None: ______________________
Occurrence
_____
Claims
Made
_____
Occurrence
_____
Claims
Made
_____
Occurrence
_____
Claims
Made
_____
Carrier ________________ Carrier _______________ Carrier _________________
Limit of Liability ________________ Limit of Liability _______________ Limit of Liability _________________
Deductible ________________ Deductible _______________ Deductible _________________
Premium ________________ Premium _______________ Premium _________________
Expiration Date ________________ Expiration Date _______________ Expiration Date _________________
Retroactive
Date
________________ Retroactive Date _______________
Retroactive
Date
_________________
4. Has any carrier
ever cancelled or refused to renew a policy issued to the Applicant?
Yes No (If yes, provide details below)
______________________________________________________________________________________________________
FEI-APP 08 08 Page 2 of 7
5. Staff: please specify the total number of staff
a. Environmental Engineers
_____
e.
Draftsmen, Technicians, Inspectors,
Surveyors: _____
b. General Engineers other than above
_____
f. Clerical and Accounting Employees:
_____
c. Geologists or Hydrogeologists
_____
g. Administrative Management:
_____
_____
d.
Industrial Hygienists, Toxicologists,
CIHs or CSPs Project Managers
_____
h.
Other: _______________________________
Total:
_____
i.
Number of Principals (included in listing
above)
_____
Please attach all key person’s resumes, certifications and licenses.
6. Specify the approximate percentage of services provided by the Applicant for each of the following categories of Clientele.
a. Commercial
____%
f. Industrial
____%
b. Contractors
____%
g. Residential – Single Family
____%
c. Design Professionals
____%
h. Residential – Multi Family
____%
d. Developers
____%
i. Utilities
____%
e. Governmental
____%
j. Other: ___________________________
____%
Business Practices
7. Does the Applicant use a standard written contract with its clients: Yes No (If yes, please answer the following &
include a copy of your standard contract)
a. Does the form contain a limitation of liability clause? Yes No (If yes, to what extent is liability limited?) ___________
______________________________________________________________________________________________________
b. Does the form contain any of the following:
_______ Hold Harmless Clause _______ Right of Entry Clause
_______ Undiscovered Hazardous Materials Clause _______ Limitation of Consequential Damages
_______ Subsurface Structure Clause _______ Ownership of Documents Clause
_______ Detailed Scope of Services
c. What percentage of your projects are contracted using:
The Applicants standard contract ______%
A letter of agreement ______%
A client’s contract form ______%
Verbal agreement ______%
Other: __________________________________ ______%
8. Are subconsultants and subcontractors hired under a written, standard subcontract?
Yes No (Please attach a copy)
9. Do you have established relationships with sub-contractors?
Yes No
10. How do you select your subcontractors?
_________________________________________________________________________________________________
Describe the minimum insurance requirements:
General Liability $________
Professional Liability $________
Contractors Pollution Liability $________
11. How are non-standard client agreements reviewed?
Attorney: Outside Attorney: In-house
Staff (Please Describe)
12. Does your firm have written quality control procedures? (If yes, please include the table of
contents with this application)
Yes No
FEI-APP 08 08 Page 3 of 7
Business Practices - continued
13. Does your firm have a written health and safety procedures? (If yes, please include the
table of contents with this application)
Yes No
14. Does your firm have an in-house continuing education program? (If yes, please describe)
Yes No
If no, please describe how your professional receives continuing education / training:
Gross Revenue
15. Enter firm’s gross revenue for the last three policy years below:
$ _________________
Estimated gross revenue for the upcoming policy year
$ _________________
1
st
prior policy year’s revenue
$ _________________
2
nd
prior policy year’s revenue
16. Percentage subcontracted to others _________% Describe services below
_______________________________________________________________________________________________
17. Detail geographical extent of operations: % Domestic:
________________
% Foreign
________________
Please provide geographical locations of all foreign projects:
18. Please provide percentage of gross revenue derived from the following operations:
Services (amounts to equal 100%)
Air Monitoring _______%
Mechanical Testing _______%
Air Testing _______% Mining Engineering _______%
Architecture _______% Mobile On-Site Laboratory _______%
Asbestos Containing Building Materials
Analysis
_______%
Mold Consulting
_______%
Bridge & Elevated Highway _______% Mold Testing or Inspection _______%
Chemical Engineering _______% Noise Level Analysis _______%
Chemical Testing _______% Noise Level Engineering _______%
Civil Engineering _______% Nuclear Engineering _______%
Construction Materials Testing _______% Process Engineering _______%
Construction Supervision/Management _______% Product Certification _______%
Electrical Engineering _______% Product Testing _______%
Environmental Consulting _______% Slope Stabilization _______%
Environmental Engineering _______% Soil Engineering _______%
Environmental Testing _______% Soil Testing _______%
Expert Witness Testimony _______% Structural Engineering _______%
Forensic Testing _______% Underground Storage Tank Testing _______%
Geology _______% Water/Waste Water Engineering _______%
Geotechnical Engineering _______% Water/Waste Water Testing _______%
Geotechnical Testing _______% Regulatory Compliance / Permitting _______%
HVAC Engineering _______% Other (please describe)
HVAC Testing or Inspection _______% __________________________________ _______%
Hydrology _______% __________________________________ _______%
Industrial Hygiene / Health & Safety _______%
Landfill Design _______%
Lead Based Paint Analysis _______%
Mechanical Engineering _______%
__________________________________
Drilling for Sampling or Monitoring Wells
_______%
_______%
FEI-APP 08 08 Page 4 of 7
Claims, Circumstances, Incidents & Loss History
19. Has any claim, suit, or notice of incident been made against your firm, a predecessor firm or an organization for which your
firm has assumed liabilities?
Yes No
If yes, please provide details. (Use additional paper if necessary.)
• Date when claim, suit or notice was made
• Date the act, error, omission for occurrence that gave rise to the claim, suit or notice
was committed
• Name of the claimant
• Nature of the claim, suit or notice
• Amount of payments made to date (including claims expenses) if open
• Amount of reserves established
• Final disposition (including amount of any settlement payment if closed)
20. Is any member of your firm or a related entity aware of any circumstances that could result in a
claim, suit or notice of incident being brought against them?
Yes No
If yes, please provide details on the same basis as the above requirements. (Use additional paper if necessary.)
21. Has any member of your firm, predecessor or any entity your firm wholly or partly owns,
manages and/or controls ever been the subject of a disciplinary action as a result of their
professional activities?
Yes No
If yes, please provide details. (Use additional paper if necessary.)
FRAUD WARNING
NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in prison.
NOTICE TO CALIFORNIA APPLICANTS: Pursuant to California Insurance Law, Sec. 1623, this application for
insurance is being submitted by an insurance broker who is acting on behalf of an insured.
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 policy holder 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.
FEI-APP 08 08 Page 5 of 7
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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 files a statement or claim or an application containing false, incomplete or misleading information is
guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that
presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment or
both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance
company or other person files 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 LOUISIANNA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a
crime and may be subject to fines and confinement in prison.
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 MARYLAND APPLICANTS: Any person who, with intent to defraud or knowing that he is
facilitation a fraud against an insurer, submits an application or files a claim containing a false or deceptive
statement may be guilty of insurance fraud.
NOTICE TO MINNESOTA APPLICANTS: A person who submits an application or files a claim with intent to
defraud or helps commit a fraud against an insurer is guilty of a crime.
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 MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a
crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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.
NOTICE TO OHIO APPLICANTS: Any person who, with 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 a 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 makes an intentional misstatement that is material to
the risk may be found guilty of insurance fraud by a court of law.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any
insurance company or other person files 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 the person to criminal and civil
penalties.
FEI-APP 08 08 Page 6 of 7
NOTICE TO TENNESSEE 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.
NOTICE TO TEXAS APPLICANTS: Any person who makes an intentional misstatement that is material to the
risk may be found guilty of insurance fraud by a court of law.
NOTICE TO VIRGINIA 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.
NOTICE TO ALL OTHER STATE APPLICANTS: Any person who knowingly includes any false or misleading
information on an application for an insurance policy is subject to criminal and civil penalties.
The applicant represents that the above statements and facts are true and that no material facts have
been suppressed or misstated and further acknowledges that the answers provided herein are based on
reasonable inquiry and/or investigation.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is
required prior to binding coverage and policy issuance.
All written statements and materials furnished to the company in conjunction with this application are
hereby incorporated by reference into this application and made a part hereof.
Applicant: _____________________________________ Title: ________________________________
Applicant’s Signature: ___________________________ Date: ________________________________
Agent / Broker Name: _____________________________________________________________________
click to sign
signature
click to edit
FREBERG ENVIRONMENTAL, INC.
INSURANCE PROGRAM MANAGERS
FEI-APP 08 08 Page 7 of 7
PROJECT DESCRIPTION - SUPPLEMENTAL PAGE
1 Project Name/Client
Services Provided:
Value of Completed Project Gross Revenue
Project Completion Date:
2 Project Name/Client
Services Provided:
Value of Completed Project Gross Revenue
Project Completion Date:
3 Project Name/Client
Services Provided:
Value of Completed Project Gross Revenue
Project Completion Date:
4 Project Name/Client
Services Provided:
Value of Completed Project Gross Revenue
Project Completion Date:
5 Project Name/Client
Services Provided:
Value of Completed Project Gross Revenue
Project Completion Date:
6 Project Name/Client
Services Provided:
Value of Completed Project Gross Revenue
Project Completion Date:
7 Project Name/Client
Services Provided:
Value of Completed Project Gross Revenue
Project Completion Date:
8 Project Name/Client
Services Provided:
Value of Completed Project Gross Revenue:
Project Completion Date:
9 Project Name/Client
Services Provided:
Value of Completed Project Gross Revenue:
Project Completion Date:
10 Project Name/Client
Services Provided:
Value of Completed Project Gross Revenue:
Project Completion Date:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

ENGINEERS, CONSULTANTS, TESTING FIRMS & LABORATORIES APPLICATION (Risk Placement Services, Inc.)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document