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Environment-Consulting-Contractor-App- Contractors and Consultants Application

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CONTRACTORS AND CONSULTANTS APPLICATION Page 1 of 4
CONTRACTORS AND CONSULTANTS APPLICATION
ENVIRONMENTAL SERVICE PROVIDERS
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 applied
against the deductible or retention amount.
ALL APPLICANTS MUST SUBMIT THE FOLLOWING INFORMATION IN ADDITION TO THE APPLICATION:
1. Completed Acord Application
2. Qualification including resumes, brochures, and a listing of previous projects.
3. Most recent income statement and balance sheet.
4. Five years of currently valued loss runs including pollution and professional, if applicable.
I. APPLICANT INFORMATION
Insured:
Date:
Address:
E-Mail:
City:
State:
Zip Code:
Phone:
Company is: Individual Partnership Corporation Joint Venture Other .
(please describe)
II. REQUESTED COVERAGE
1. Coverage Requested: (please clearly state what coverage(s) you are requesting)
New Business Renewal
2. Proposed Effective Date:
Proposed Retroactive Date:
Expiring Retroactive Date:
( Occurrence, or
( Occurrence, or
Claims Made)
Claims Made)
3. Limits Of Liability/Deductible:
Limits Requested:
Deductible Requested:
4. Other Coverages and
Endorsements:
.
Errors and Omissions (Claims Made Only)
Pollution Legal Liability (Claims Made Only) Third Party Pollution Liability
On-Site Clean Up
III. GROSS RECEIPTS
Please indicate gross receipts for the prior three years:
Prior Year Revenues
(Past 12 Months)
Current Year Revenues
(Current 12 Months)
Estimated Revenues
(Upcoming 12 Months)
$
$
$
Indicate Month/Date below:
to
Indicate Month/Date below:
to
Indicate Month/Date below:
to
Note: Gross Receipts are the total of all receipts, invoices and/or billing without any deductions of any kind. Please list
your estimated receipts including subcontracted work for the next 12 months next to the appropriate category. List
services not described below under “Other” (please be specific):
4. Environmental Contracting
6. Consulting/Laboratory
Above Ground Storage Tank Installation
$
Air Monitoring
$
Above Ground Storage Tank Removal
$
Analytical Laboratories
$
Asbestos Abatement
$
Civil Engineering
$
Bio Remediation
$
Environmental Compliance
$
Clear Form
To Submit: Save then email to
inspectors@orep.org
CONTRACTORS AND CONSULTANTS APPLICATION Page 2 of 4
Drilling (not oil/gas)
$
Environmental Impact Studies
$
Emergency Response
$
Environmental Permitting
$
Haz Mat Clean Up
$
Environmental Sampling
$
Haz Mat Packing / Pickup
$
Expert Witness
$
Lead Abatement
$
Geophysical (i.e. drilling, sampling, etc.)
$
Liquid Waste Remediation
$
Geotechnical (i.e. foundation, retaining wall,
slope stability, etc.)
$
Mold Remediation
$
PCB Removal / Remediation
$
Haz Mat Consulting
$
Soil Removal / Remediation
$
Hydrogeological Investigations
$
Soil Excavation – other than petroleum
$
Indoor Air Quality
$
Tank &/or Pipe Cleaning
$
Industrial Hygiene / HASP
$
Underground Storage Tank Installation
$
Litigation Support
$
Underground Storage Tank Removal
$
Manual Preparation
$
Wetlands Contracting
$
Mold Evaluation / Consulting
$
5. Non-Environmental Contracting
Phase I Environmental Assessments
$
Carpentry
$
Phase II & III Environmental Assessments
$
Demolition
$
Project Management
$
Electrical
$
Remedial Investigation / Studies
$
Fire / Water Restoration
$
Remedial Design
$
General Contractor
$
Remediation Oversight
$
Grading Contractor
$
Safety Training
$
Industrial Cleaning
$
Underground Storage Tank Testing
$
Maintenance/Janitorial
$
Wetlands
$
Masonry
$
Mechanical Construction
$
Other – Consulting / Laboratory
Metal Erection
$
Describe:
$
Painting
$
Describe:
$
Paving
$
Pipeline Installation
$
Plumbing
$
Roofing
$
Oil and Gas
$
Street and Road
$
Other – Contracting
Describe:
$
Describe:
$
Describe:
$
Describe:
$
Total Projected Contracting
Gross Receipts:
$
Total Projected Consulting/
Laboratory Gross Receipts:
$
IV. SUBCONTRACTED SERVICES
1. Please identify the services that are subcontracted:
2. Applicable Cost:
Description:
$
Description:
$
Description:
$
Description:
$
CONTRACTORS AND CONSULTANTS APPLICATION Page 3 of 4
3. Are all subcontractors licensed and accredited?
Yes
No
4. Does the applicant collect certificates of insurance from all subcontractors?
Yes
No
5. Are the subcontractors required to name the applicant as an additional insured?
Yes
No
6. Is a standard written contract used with the applicant’s clients and/or subcontractors, including
hold harmless and limitation of liability clause?
Yes
No
V. GENERAL INFORMATION
1. Does the applicant directly or indirectly perform work on residential properties?
Yes
No
If yes, what percentage of the applicant’s overall sales are associated with this operation?
%
2. Are more than 50% of the applicant’s services subcontracted?
Yes
No
3. Is the applicant applying for project specific coverage?
Yes
No
If yes, please attach a copy of the contract for the project and project supplemental application.
4. Does the applicant conduct more than 10% geotechnical or geophysical operations?
Yes
No
If yes, what percentage of the applicant’s overall sales are associated with this operation?
%
Please submit the following: A detailed list of the applicant’s geotechnical and geophysical operations & detailed
resumes of employees who conduct these operations.
5. Does the applicant install any type of liner, i.e. landfill, lagoons, etc.?
Yes
No
If yes, what percentage of the applicant’s overall sales are associated with this operation?
%
Please submit the following: Resumes and certifications of employees installing the liners, installation procedures &
testing procedures for the installed liner.
6. Does the applicant conduct tank installation work?
If yes, please answer the following:
Yes
No
a) What percentage of the applicants overall sales are associated with this operation:
%
b) Are the installed tanks precision tightness tested before being released to owner?
Yes
No
c) Does the applicant apply any type of corrosion protection?
Yes
No
d) Are tanks tested and certified by a registered professional before use?
Yes
No
Please submit the following: Resumes and certifications of all tank installation employees, type of tanks applicant
installs, type of corrosion protection applicant installs & installation procedures.
7. Are any of the applicant’s revenues generated by contracting services performed in New York City?
Yes
No
If yes, what percentage of the applicant’s overall sales are associated with this operation?
%
8. Does the applicant conduct any type of mold contracting or mold consulting work?
Yes
No
If yes, please complete and attach a Supplemental Mold Contractors and Consultants Application.
If no, but the applicant is interested in being considered for mold coverage for claims that may arise from the
applicant’s contracting operations, please complete and attach a Supplemental Mold Application.
9. Does the applicant conduct any Phase I or Real Estate Transfer Assessments?
If yes, please answer the following:
Yes
No
a) What percentage of the applicants overall sales are associated with this operation:
%
b) Does the applicant follow ASTM-1527 guidelines?
If no, please attach a sample contract of the applicant’s format.
Yes
No
10. Total personnel (List each person only once, by primary function):
a) Architects, Engineers, Geologists, Hydrogeologists
b) Industrial Hygienists, Toxicologists, CIHs or CSPs
c) Supervisors/Foremen/Leadmen
d) Draftsmen, Technicians
e) Laborers
f ) AHERA, Hazwopers
g) Other (please specify primary function and count per primary function):
VI. CLAIMS INFORMATION
11. 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:
CONTRACTORS AND CONSULTANTS APPLICATION Page 4 of 4
12. 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 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:
VII. HISTORY OF COMPANY
1. Date Company Was Established: .
5. Is the applicant a successor of any other
business? If yes, please list predecessor in
the area below.
Yes
No
2. Is the applicant, or any affiliated, related predecessor
entity currently involved with sharing office space, use
of employees or commingling of affiliated or related
operations or services of any kind? If yes, please
provide an explanation in the area below.
Yes
No
6. Has the applicant, or any affiliated, related
predecessor entity or any officer or owner
ever been convicted of a crime? If yes,
please provide an explanation in the area
below.
Yes
No
3. Is work done through or by any affiliated or related
company(s)? If yes, please provide an explanation in
the area below.
Yes
No
7. Has the applicant, or any affiliated, related
predecessor entity ever been (or currently is)
the subject of bankruptcy, reorganization,
solvency, dissolution or other debtor related
proceedings and/or has made assignment for
the benefit of creditors? If yes, please
provide an explanation in the area below.
Yes
No
4. Is the applicant, or any affiliated, related predecessor
entity currently involved in any litigation, administrative
or arbitration proceeding(s) or subject to any court or
agency order or injunction? If yes, please provide an
explanation in the area below.
Yes
No
8. If you answered “yes” to any of the questions listed above, please include a detailed explanation:
VII. PRIOR LIABILITY CARRIER INFORMATION (Past three years)
Coverage Form
Carrier
Receipts
Limit of Liability
Deductible
Type of Policy
Rate
Premium
1.
2.
3.
4. Has any policy or coverage been declined, cancelled and/or non-renewed during the prior three years?
Yes (If yes, please explain):
No
FRAUD WARNING: APPLICABLE TO ALL 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 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.
WARRANTY STATEMENT
The signatory declares that (s)he is authorized by the Applicant to sign this application on behalf of all prospective Insureds
and that to the best of his/her knowledge the statements herein are true. The signatory agrees that if the information supplied
in this application and the materials submitted therewith should change between the date this application is signed and the
effective date of the proposed insurance, the signatory shall immediately notify the Insurer of such and shall provide the
Insurer with information that would complete, update or correct the application or materials submitted therewith. The Insurer
may withdraw or modify any of the terms or conditions of coverage accordingly.
NOTICE TO APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance containing any false information, or conceals for the purpose of misleading, information
concerning fact material thereto, commits a fraudulent insurance act, which is a crime.
Signature:
Date:
Print Name:
Title:
Please submit your application to your OREP Agent: || 888-347-5273
inspectors@orep.org
OREP–Organization of Real Estate Professionals Insurance Services, LLC. Calif. Lic. #0K99465
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Environment-Consulting-Contractor-App- Contractors and Consultants Application

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Completed 2 July 2020

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