Fillable Form 2.: APPLICATION FOR ENVIRONMENTAL CONSULTANTS PR OFESSIONAL (Risk Placement Services, Inc.)

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Form 2.: APPLICATION FOR ENVIRONMENTAL CONSULTANTS PR OFESSIONAL (Risk Placement Services, Inc.)

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EIC 1949-03 1/02 Page 1 of 3
APPLICATION FOR ENVIRONMENTAL CONSULTANTS
PR
OFESSIONAL LIABILITY INSURANCE POLICY
(Claims Made Basis)
APPLICANT’S INSTRUCTIONS:
1. Answer all questions. If the answer requires detail, please attach a separate sheet.
2.
Application must be signed and dated by owner, partner or officer.
3. PLEASE READ CAREFULLY THE STATEMENTS AT THE END OF THIS APPLICATION.
(PLEASE TYPE OR PRINT IN INK)
1. APPLICANT INFORMATION
a. Full Name of Applicant:
b. Principal business premise address:
(Street) (County)
(City) (State) (Zip)
c. [ ] Corporation? [ ] Partnership? [ ] Individual? [ ] Other
d. Years in business under present name:
e. List and describe affiliations with other firms:
f. List and describe any corporate name changes, mergers, and/or consolidations (within the past 3 years):
2. STAFF
List number of total personnel using the following categories:
_____ Architects or design engineers _____ Industrial hygienists or toxicologist
_____ General engineers other than above _____ Draftsmen or technicians
_____ Geologists or hydrogeologists _____ Clerical or accounting
_____ Environmental scientists _____ Administrative management
How many of the above personnel possess professional engineering designations? ____________
3. OPERATIONS
a. Please provide a description of professional activities for which coverage is desired:
b. Please describe your use of subcontractors, including type of work and percentage of gross receipts:
EIC 1949-03 1/02 Page 2 of 3
c. Please provide gross receipts attributable to the following:
Prior Current Projected
Service Year Year Year
Environmental studies, assessments, reports, audits _________ _________ _________
Remedial studies, investigations where firm is not involved in design _________ _________ _________
Site selection evaluation (real estate, waste) _________ _________ _________
Environmental permit preparation, submission _________ _________ _________
Remedial design with supervisory services _________ _________ _________
Remedial design without supervisory services _________ _________ _________
Project monitoring, management _________ _________ _________
General consulting _________ _________ _________
Laboratory services _________ _________ _________
Total _________ _________ _________
Other (describe below):
d. Please provide the percentage of work performed for the following:
1) Federal government _________% 4) Individuals, partnerships, joint ventures ______%
2) State government _________% 5) Contractors ______%
3) Private or public corporations _________%
4. HISTORY/CLAIMS
a. Are you aware of any facts or circumstances, during the past 5 years, which may give rise to a claim? ...... [ ] Yes [ ] No
If Yes, please describe on a separate sheet.
b. Have any professional liability claim been made against you or any of your employees in the
past 5 years? ........................................................................................................................................... [ ] Yes [ ] No
If Yes, please describe on a separate sheet.
c. Please list previous errors & omissions coverage for the past 4 years.
Policy Period Insurance Carrier Limits of Liability Premium Deductible or S.I.R.
______________ _________________________ _____________ __________ ________________
______________ _________________________ _____________ __________ ________________
______________ _________________________ _____________ __________ ________________
______________ _________________________ _____________ __________ ________________
5. ADDITIONAL INFORMATION
Please include the following:
_____ Most recent financial statement
_____ Sample of client/subcontractor contract
_____ Company marketing literature
_____ Statement of qualifications or resumes of key personnel
_____ Client reference and/or representative project listing
Please be as complete as possible when providing the above outlined information. This will enable the underwriter to provide
the best possible terms and conditions.
* NOTICE TO APPLICANT: The coverage applied for is SOLELY AS STATED IN THE POLICY, which provides coverage on a
"CLAIMS MADE" basis for ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY
PERIOD unless the extended reporting period option is exercised in accordance with the terms of the policy.
EIC 1949-03 1/02 Page 3 of 3
WARRANTY: I/We warrant to the Insurer, that I understand and accept the notice stated above and that the information contained
herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Insurer evidence
its acceptance of this application by issuance of a policy. I/We authorize the release of claim information from any prior insurer to
Shand Morahan & Company, Inc., Underwriting Manager for the Company.
Name of Applicant* Title (Officer, partner, etc.)
Signature of Applicant Date
SIGNING this application does not bind the Applicant or the Insurer or the Underwriting Manager to complete the insurance, but one
copy of this application will be attached to the policy, if issued.
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Form 2.: APPLICATION FOR ENVIRONMENTAL CONSULTANTS PR OFESSIONAL (Risk Placement Services, Inc.)

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Completed 30 July 2020

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