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ENVIRONMENTAL SERVICE PROVIDERS APPLICATION (Risk Placement Services, Inc.)

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SCOBIE GROUP-TOWER SPECIAL FACILITIES
N14 W23777 STONE RIDGE DRIVE, SUITE 140
WAUKESHA, WI 53188-1158
PH: 800-837-1525/262-513-6000
FAX: 262-513-6010
www.towerspecial.com
FEI-300-ECC-0708 Page 1 of 7
ENVIRONMENTAL SERVICE PROVIDERS APPLICATION
APPLICANT DATE
ADDRESS
CITY STATE ZIP
TELEPHONE WEB ADDRESS
Company 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 Description – 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 Occurrence Form
Claims Made Form Retroactive date __/__/__
CONTRACTOR’S POLLUTION LIABILITY Occurrence Form
Claims Made Form Retroactive date __/__/__
PROFESSIONAL LIABILITY
Claims Made Form only Retroactive date
__/__/__
SITE POLLUTION LIABILITY
Claims Made Form only Retroactive date
__/__/__
Company 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 refused to renew or instigated cancellation with respect to a liability policy issued to the Applicant, a
predecessor in business, or a person, firm or organization for whom the Applicant has assumed the liabilities of has a liability policy
issued to any of the aforementioned ever been cancelled at the instigation of any premium finance company?
Yes No
(provide details below)
______________________________________________________________________________________________________
______________________________________________________________________________________________________
FEI-300-ECC-0708 Page 2 of 7
5. Staff: Specify the total number of staff as follows
a. Architects or 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.
The total must equal 100%
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 Legal 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-300-ECC-0708 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)
14. Does your firm have a confined space protocol? (If yes, please include the table of
contents with this application)
Yes No
Yes No
15. 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:
16. Enter firm’s gross revenue for the last three years below:
Fiscal Year Period: ____________________ to ____________________
$ _________________ Estimated gross revenue for the upcoming year
$ _________________ 1
st
prior year’s revenue
$ _________________ 2
nd
prior year’s revenue
17. What percentage of estimated receipts is subcontracted to others
_________%
(Describe services below)
___________________________________________________________________________________________________
18. Detail geographical extent of
operations:
% Domestic:
________________
% Foreign
________________
Please provide geographical locations of all foreign projects:
19. Please provide percentage of gross revenue derived from the following operations:
Services (amounts must total 100%)
Above Ground Storage Tank Installation _______% Regulatory Compliance / Permitting _______%
Lab-packing / Drum Handling _______% Industrial Hygiene / Health & Safety _______%
Industrial Cleaning _______% Phase II & III Environmental Assessment _______%
Tank Cleaning _______% General Consulting (Please Describe)
Soil Excavation - petroleum _______%
Thermal Treatment _______% __________________________________ _______%
Underground Storage Tank Removal _______% Project Management _______%
Underground Storage Tank Installation _______% Training (Please Describe)
Home Heating Oil Tank Removal _______%
Home Heating Oil Tank Installation _______% __________________________________ _______%
Drilling _______% Analytical Laboratories _______%
Sampling _______% Lead & Asbestos Consulting _______%
Emergency Response _______% Remediation Oversight _______%
Bioremediation _______% Remedial Design _______%
Soil remediation _______% Hydrogeological Investigations _______%
Soil excavation - other than petroleum _______% Underground Storage Tank Testing _______%
Asbestos Remediation _______% Phase I Environmental Assessments _______%
Lead Based Paint Remediation _______% Mold evaluation _______%
Mold Remediation _______% Geotechnical Engineering _______%
Hazardous Waste Cleanup _______% Civil Engineering _______%
Demolition (Please Describe) Process Engineering _______%
__________________________________ _______%
Roofing – Commercial _______%
Roofing – Residential _______%
Pesticide / Herbicide Application _______%
Other (please describe)
__________________________________ _______%
FEI-300-ECC-0708 Page 4 of 7
Claims, Circumstances, Incidents & Loss History
20. In the past 3 years, 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)
- 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 the initial demand
- Maximum amount of reserves established
- Final disposition (including amount of settlement payment)
21. In the past 3 years, has 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 full details on the same basis as the above requirements (use additional paper if necessary)
22. In the past 3 years 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)
FEI-300-ECC-0708 Page 5 of 7
FRAUD WARNING
NOTICE TO
ALABAMA, ALASKA, ARIZONA, ARKANSAS, CONNECTICUT, DELAWARE, GEORGIA,
IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS, MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA,
MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH,
VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN, AND WYOMING APPLICANTS: In some 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, for the purpose of
misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act
which is a crime in many states.
NOTICE TO CALIFORNIA APPLICANTS: In some 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, for the purpose of misleading, conceals information concerning
any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
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 for the purpose of defrauding or attempting to defraud the policyholder
or claiming with regard to a settlement or award payable for 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 insurance company files a statement of claim containing any 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 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 OHIO APPLICANTS: “Any person who, with intent to defraud or knowing that he/she 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.”
FEI-300-ECC-0708 Page 6 of 7
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 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.”
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: In some 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, for the purpose of misleading, conceals information concerning any fact material
thereto, may commit a fraudulent insurance act which is a crime in many states.
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.
The applicant represents that the above statements and facts are true and that no material facts have
been suppressed or misstated.
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.
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
$5,000 and the stated value of the claim for each such violation.”
Applicant: _____________________________________ Title: ________________________________
FEIN #: _____________________________________
Applicant’s Signature: ___________________________ Date: ________________________________
Agent / Broker Name: _____________________________________________________________________
The applicant further acknowledges that the answers provided herein are based on a reasonable inquiry
and/or investigation.
FEI-300-ECC-0708 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:
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ENVIRONMENTAL SERVICE PROVIDERS APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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