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ENVIRONMENTAL SERVICE PROVIDERS / CONTRACTORS /CONSULTANTS/ ENGINEERING / (Risk Placement Services, Inc.)

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MAEI 1000 04 12 Page 1 of 8
ENVIRONMENTAL SERVICE PROVIDERS / CONTRACTORS /CONSULTANTS/
ENGINEERING / ENVIRONMENTAL PROFESSIONALS
COMBINED SERVICE APPLICATION
PLEASE ANSWER ALL QUESTIONS COMPLETELY
NOTICE: For certain policies and coverage parts issued, the limit of liability available to pay judgments for settlements
shall be reduced by amounts incurred for legal defense. Further note that amounts incurred for legal defense shall be ap-
plied against the deductible or retention amount.
ALL APPLICANTS MUST SUBMIT THE FOLLOWING INFORMATION IN ADDITION TO THE APPLICATION:
1. Qualifications including resumes/certifications of key personnel along with company brochures
2. Most recent income statement and balance sheet
3. Five years of currently valued loss runs for all named insureds including general, pollution, and professional liability
4. Completed Acord Application
5. Sample of typical company contract
A. APPLICANT INFORMATION:
Applicant: Date:
Inspection Contact Name: Phone:
Address:
City: State: Zip Code:
Company Website: D&B No.:
Company is an: Individual Partnership Corporation Joint Venture Other
(please describe)
B. COVERAGE
New Business Renewal
1
Special Project
2
1
Please complete Contractors/Consultants Renewal Application.
2
Please attach copy of Project Contract and complete Project Supplemental Application.
REQUESTED COVERAGE
CGL Effective Date: Retroactive Date:
CM OCC
CPL Effective Date: Retroactive Date:
CM OCC
Prof. Liability
EIL
Limits of Liabi
lity:$
Deductible/SIR:$
Endorsements/Other Coverages:
MAEI 1000 04 12
Page 2 of 8
The following entities are to be listed as named insureds on the policy. Please list any ownership/relationship information:
PRIOR LIABILITY COVERAGE (LAST 3 YEARS)
$ $
$
$ $
$
$ $
$
Has any policy or coverage been declined, cancelled, and/or non-renewed during the prior 3 years?
Yes No
If yes, please provide a detailed explanation.
C. HISTORY OF COMPANY
1. Years Performing Services to be Covered
by this insurance policy .
4. Is the Applicant a successor of any other busi-
ness? If yes, please list predecessor.
Yes
No
2. Is work done through or by any affiliated or
related company(s)? If yes, please explain.
Yes
No
5. Is the Applicant directly or indirectly controlled,
owned, or otherwise managed by another party? If
yes, please explain.
Yes
No
3. Is the Applicant or any affiliated, related
predecessor entity currently involved with
sharing office space, use of employees, co-
mingling of affiliated or related operations of
any kind? If yes, please explain.
Yes
No
6. Does the Applicant directly or indirectly control,
own, or otherwise manage any other entity? If
yes, please explain.
Yes
No
D. GROSS ANNUAL REVENUE (HISTORICAL)
1
1
Gross Annual Revenue includes the total of all receipts, invoices, and/or billing without deductions of any kind.
1. Please list your Total Gross Annual Revenues for the preceding 3 years:
1st Prior Year $
2nd Prior Year $
3rd Prior Year $ ________________________
2.
What percentage of the time do you work without a written contract? %
3.
Does the Applicant directly or indirectly perform work on residential properties?
Yes No
If yes, what percentage of the Applicant's overall sales is associated with residen
tial work?
%
4.
Do you ever work with
sub
contractors?
Yes No
Type of Cover-
age
Carrier
Effective
Date
Retroactive
Date
Limits of
Liability
Deductible/
SIR
Gross Annual
Revenue
MAEI 1000 04 12
Page 3 of 8
If yes, please answer the following questions:
a.
Are all subcontractors licensed and accredited?
Yes No
b.
Do you maintain current certificates of insurance from all subcontractors?
Yes No
c.
Is a standard written contract used with the Applicant's clients/or subcontrac-
tors? Does that contract include Hold Harmless and Limitation of Liability
clauses?
Yes No
d.
What are the minimum limits of liability required of your subcontractors?
e.
What percentage of the time are you added as an additional insured on the
subcontractor’s policy?
%
E. GROSS ANNUAL REVENUE (FOR THE NEXT 12 MONTH PERIOD)
Please list your Estimated Gross Annual Revenue including any subcontracted work for the next 12 months under the ap-
plicable categories below. Gross Annual Revenue includes the total of all receipts, invoices, and/or billing without deduc-
tions of any kind.
Services Provided Gross Revenue
% Sub-
contracted
(if any)
AIR MONITORING
$
%
ENVIRONMENTAL COMPLIANCE
$
%
ENVIRONMENTAL EXPERT WITNESS
$
%
ENVIRONMENTAL FEASIBILITY STUDIES
$
%
ENVIRONMENTAL IMPACT STUDIES
$
%
ENVIRONMENTAL LABORATORIES
$
%
ENVIRONMENTAL LITIGATION SUPPORT
$
%
ENVIRONMENTAL MANUAL PREPARATION
$
%
ENVIRONMENTAL PERMITTING
$
%
ENVIRONMENTAL REMEDIAL INVESTIGATION
$
%
ENVIRONMENTAL SAMPLING
$
%
GEOTECHNICAL CONSULTING
$
%
GEOPHYSICAL CONSULTING
$
%
HAZARDOUS MATERIALS CONSULTING
$
%
INDOOR AIR QUALITY CONSULTING
$
%
INDUSTRIAL HYGIENE/HEALTH & SAFETY CONSULTING
$
%
MOLD CONSULTING SERVICES
1
$
%
PHASE I-ESA
$
%
PHASE II- ESA $ %
PHASE III- ESA
$
%
RADON TESTING
$
%
SAFETY TRAINING
$
%
UNDERGROUND STORAGE TANK TESTING
$
%
WETLANDS CONSULTING
$
%
WILDLIFE STUDIES
$
%
TOTAL Revenue Environment Consulting
$ 100%
NOTE: Items marked with a
1
above for Mold Contractors/Consultants. If Applicant performs any of these services, a Sup-
plemental Mold Contractors/Consultants Addendum MUST BE COMPLETED and ATTACHED for coverage considera-
tion.
MAEI 1000 04 12
Page 4 of 8
Services Provided Gross Revenue
% Sub-
contracted
(if any)
ASBESTOS ABATEMENT CONTRACTING
$
%
ENVIRONMENTAL DRILLING (NOT OIL/GAS)
$
%
ENVIRONMENTAL EMERGENCY RESPONSE CONTRACTING (SPILL
CLEAN-UP) $
%
GROUNDWATER REMEDIATION CONTRACTING
$
%
HAZARDOUS MATERIAL CLEAN-UP CONTRACTING
$
%
ILLEGAL DRUG LAB CLEAN-UP CONTRACTING
$
%
LANDFILL CONSTRUCTION CONTRACTING
$
%
LEAD-BASED PAINT ABATEMENT CONTRACTING
$
%
LIQUID WASTE REMEDIATION CONTRACTING
$
%
MEDICAL WASTE PICKUP $ %
MEDICAL WASTE REMEDIATION CONTRACTING
$
%
MOLD CONTRACTING SERVICES
1
$
%
MOLD, FIRE, WATER, OR STORM DAMAGE RESTORATION CONTRACT-
ING
1
$
%
PCB LIGHT BALLAST REMOVAL
$
%
PCB REMOVAL/REMEDIATION CONTRACTING
$
%
RADON MITIGATION CONTRACTING
$
%
SERVICE STATION CONTRACTING-AST INSTALLATION
$
%
SERVICE STATION CONTRACTING-AST REMOVAL CONTRACTING
$
%
SERVICE STATION CONTRACTING-BUILDING, CONSTRUCTION, CON-
CRETE, ELECTRIC)
$
%
SERVICE STATION CONTRACTING- FUEL SYSTEM EQUIPMENT INSTAL-
LATION SERVICE & MAINTENANCE (NON-TANK)
$
%
SERVICE STATION CONTRACTING-STORAGE TANK & PART SALES (NO
INSTALLATION)
$
%
SERVICE STATION CONTRACTING-STORAGE TANK & PIPE CLEANING
CONTRACTING $
%
SERVICE STATION CONTRACTING-UST INSTALLATION CONTRACTING
$
%
SERVICE STATION CONTRACTING-UST REMOVAL $
%
SOIL REMEDIATION CONTRACTING-BIOREMEDIATION
$
%
SOIL REMEDIATION CONTRACTING-(OTHER THAN PETROLEUM CON-
TAMINATED SOIL)
$
%
SOIL REMEDIATION CONTRACTING-(PETROLEUM CONTAMINATED
SOIL) $
%
TRUCKING-HAZARDOUS MATERIAL
$
%
WASTE INCINERATION
$
%
WASTEWATER TREATMENT SYSTEM INSTALL/MAINTENANCE
$
%
WATER EXTRACTION CONTRACTING
$
%
WETLANDS CONTRACTING
$
%
TOTAL Revenue Environmental Contracting $ 100%
NOTE: Items marked with a
1
above for Mold Contractors/Consultants. If Applicant performs any of these services, a Sup-
plemental Mold Contractors/Consultants Addendum MUST BE COMPLETED and ATTACHED for coverage considera-
tion.
MAEI 1000 04 12
Page 5 of 8
Services Provided Gross Revenue
% Sub-
contracted
(if any)
AIRCRAFT REFUELING
$
%
CARPENTRY
$
%
CARPET/FLOOR COVERING INSTALLATION
$
%
CLEARING OF LAND/GROUNDSKEEPING
$
%
CONCRETE
$
%
CRIME SCENE CLEAN-UP
$
%
DEMOLITION-NON-STRUCTURAL
$
%
DEMOLITION-STRUCTURAL-UNDER 3 STORIES
$
%
DEMOLITION-STRUCTURAL-OVER 3 STORIES
$
%
DRYWALL/GYPSUM WALLBOARD INSTALL/REPAIR
$
%
ELECTRICAL INCLUDING ELECTRONICS (INSTALL/REPAIR)
$
%
EXCAVATION (NON-CONTAMINATED SOILS)
$
%
FIRE SUPPRESSION SYSTEMS (INSTALL/MAINTAIN)
$
%
FOUNDATION
$
%
GENERAL CONTRCTING-BUILD BACK/RESTORATION
$
%
GENERAL CONTRACTING-DEMOLITION-INTERIOR ONLY
$
%
GENERAL CONTRACTING-DEMOLITION-UNDER 2 STORIES
$
%
GENERAL CONTRACTING-DEMOLITION-OVER 2 STORIES
$
%
GENERAL CONTRACTING-EXCAVATION
$
%
GENERAL CONTRACTING-INSULATION INSTALLATION
$
%
GENERAL CONTRACTING-DRILLING-NON-ENVIRONMENTAL (NON-
OIL/GAS) $
%
GENERAL CONTRACTING-NON-HAZARDOUS MATERIAL
$
%
GRADING OF LAND
$
%
HVAC
$
%
MASONRY
$
%
MODULAR CONSTRUCTION
$
%
PAINTING
$
%
PAVING/ASPHALT APPLICATION
$
%
PLANT REPAIR/MAINTENANCE INCLUDING JANITORIAL
$
%
PLUMBING
$
%
ROOFING
$
%
STEEL ERECTION-NON-STRUCTURAL
$
%
STEEL ERECTION-STRUCTURAL
$
%
STREET & ROADS INCLUDING ICE & DIRT
$
%
TANK/PIPE CLEANING
$
%
TRANSPORTATION-MEDICAL WASTE/BIOHAZARD
$
%
TRANSPORTATION-REFUSE/TRASH
$
%
TRUCKING-NON- HAZARDOUS MATERIAL
$
%
WEATHERIZATION
$
%
WELDING
$
%
TOTAL Revenue Non-Environmental Contracting
$
100%
NOTE: Any Applicant interested in obtaining coverage for mold claims which may arise from Applicant's contracting op-
erations (claims made) MUST COMPLETE and ATTACH Mold Application.
MAEI 1000 04 12
Page 6 of 8
F. COMPANY PROFILE
Personnel
Please list the TOTAL personnel by area of expertise and highest degree obtained. Add designations as necessary.
Designation #
Highest
Degree
Obtained
Env. Consultant Env. Contractor
Non- Env.
Contractor
CERTIFIED INDUSTRIAL HYGIEN-
IST (CIH)
INDUSTRIAL HYGIENIST
MICROBIOLOGIST/TOXICOLOGIST
PROFESSIONAL ENGINEER (PE)
CERTIFIED SAFETY PROFES-
SIONAL (CSP)
GEOLOGIST/HYDROGEOLOGIST
PROJECT MANAGER/ENV.
CHEMIST/BIOLOGIST
ARCHITECT
SUPERVISOR/ FOREMAN
DRAFTSMAN
TECHNICIAN (WITH ENV. CER-
TIFICATES.)
WORKER
OTHER
Projects
By revenue, list 3 to 5 of your largest projects in the preceding three years.
Revenue Service Provided Project Name Client
$
$
$
$
$
1.
Is more than 50% of Applicant's work performed for any one client?
If yes, please identify client and service provided.
Yes No
2.
Is more the 50% of Applicant's work performed in any one particular location?
If yes, please identify location.
Yes No
3.
Does Applicant provide services or perform work in any of the 5 boroughs of New York
City (Bronx, Brooklyn, Queens, Staten Island, Manhattan) Nassau, Westchester, or
Erie County New York?
If yes, please describe services provided and percentage (%) of revenue generated
from those services.
Yes
%
No
MAEI 1000 04 12
Page 7 of 8
Project Revenue by Client Type
Please complete the percentage(%) of revenue attributable to the following client types
Client Type % of
Revenue
Client Type % of
Revenue
COMMERCIAL INDUSTRIAL
OFFICE % MANUFACTURING %
SCHOOLS % REFINERIES
%
HOSPITALITY % PIPELINE %
RETAIL % CHEMICAL PLANTS %
WAREHOUSE % POWER/ENERGY %
CHURCHES % WASTEWATER TREATMENT %
CONVENTION % RECYCLING %
ARENAS % OTHER %
TRANSPORT CENTERS %
GOVERNMENTAL
OTHER % FEDERAL %
HEALTHCARE
STATE/LOCAL %
HOSPITALS % OTHER %
NURSING HOMES/ASSISTED LIVING %
INFRASTRUCTURE
AMBULATORY/OUTPATIENT % AIRPORTS %
OFFICES % ROADS %
OTHER % BRIDGES %
RESIDENTIAL
TUNNELS %
APARTMENTS % NUCLEAR %
CONDOMINIUMS % LANDFILLS %
DORMITORIES % HARBORS/PORTS %
SINGLE FAMILY % MASS TRANSIT %
PRISONS % RAILROADS %
OTHER % PARKING STRUCTURES %
OTHER %
G. GENERAL INFORMATION
1. Is the Applicant aware of any circumstances, which may result in any claim, suit or notice of incident against him
the firm, his predecessors in business, any of the present or past partners or officers, or any staff member and/or
has any staff member and/or has any claim, suit or notice of incident been made against the firm or any staff
member?
Yes No
If yes, please provide full details on each incident:
2. While we attempt to make this application comprehensive, we invite the Applicant to list below any other items(s)
which you feel could be important for Markel to consider prior to making a coverage determination.
FRAUD WARNINGS:
Notice to Arkansas and West Virginia 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 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 impris-
onment, 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 policyholder 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 in-
surer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
MAEI 1000 04 12
Page 8 of 8
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 mis-
leading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Notice to Maine Applicants: It is a crime to knowingly provide false, incomplete or misleading information to an insur-
ance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insur-
ance benefits.
Notice to Maryland Applicants: Any person who knowingly and willfully presents a false or fraudulent claim for payment
of a loss or benefit or who knowingly and willfully 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 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 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.
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 any claim for the proceeds of an insurance policy containing any false, incomplete or misleading infor-
mation is guilty of a felony.
Notice to Oregon Applicants: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud
against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insur-
ance fraud.
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 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 such person to criminal and civil penalties.
Notice to Tennessee, Virginia and Washington Applicants: It is a crime to knowingly provide false, incomplete or mis-
leading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment,
fines and denial of insurance benefits.
Notice to Vermont Applicants: Any person who knowingly presents a false statement in an application for insurance
may be guilty of a criminal offense and subject to penalties under state law.
Notice to Applicants of all other 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 subjects the person to criminal and civil penalties.
WARRANTY STATEMENT
The undersigned authorized officer of the Applicant declares that the statements set forth herein are true. The under-
signed authorized officer agrees that if the information supplied on the application changes between the date of the appli-
cation 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 insur-
ance. Signing of this application does not bind the Applicant to the insurer to complete the insurance.
___________________________________________
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ENVIRONMENTAL SERVICE PROVIDERS CONTRACTORS CONSULTANTS ENGINEERING (Risk Placement Services, Inc.)

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Completed 30 July 2020

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