o o o o o o PLEASE ANSWER ALL QUESTIONS COMPLETELY

Transcription

1 Deerfield Insurance Cmpany Evanstn Insurance Cmpany Essex Insurance Cmpany Markel American Insurance Cmpany Markel Insurance Cmpany Assciated Internatinal Insurance Cmpany CONTRACTORS AND CONSULTANTS APPLICATION PLEASE ANSWER ALL QUESTIONS COMPLETELY NOTICE: Fr certain plicies and cverage parts issued, the limit f liability available t pay judgments fr settlements shall be reduced by amunts incurred fr legal defense. Further nte that amunts incurred fr legal defense shall be applied against the deductible r retentin amunt. ALL APPLICANTS MUST SUBMIT THE FOLLOWING INFORMATION IN ADDITION TO THE APPLICATION: 1. Qualificatin including resumes, brchures, and a listing f previus prjects. 2. Mst recent incme statement and balance sheet. 3. Five years f currently valued lss runs including pllutin and prfessinal, if applicable. 4. Cmpleted Acrd Applicatin. A. APPLICANT INFORMATION Applicant: Date: Address: City: State: Zip Cde: Phne: Cmpany is an: Individual Partnership Crpratin Jint Venture Other. (please describe) B. REQUESTED COVERAGE 1. Cverage Requested: (please clearly state what cverage(s) yu are requesting) New Business Renewal 2. Prpsed Effective Date: Prpsed Retractive Date: Cmmercial General Liability Cntractrs Pllutin Liability ( Occurrence, Claims Made) ( Occurrence, Claims Made) Prfessinal Liability (Claims Made Only) Envirnmental Impairment Liability (Claims Made Only) 3. Limits Of Liability/Deductible: Limits Requested: Deductible Requested: 4. Other Cverages and Endrsements:. C. HISTORY OF COMPANY 1. Date Cmpany Was Established:. 2. Is wrk dne thrugh r by any affiliated r related cmpany(s)? If yes, please prvide an explanatin in the area belw. 3. Is the applicant, r any affiliated, related predecessr entity currently invlved with sharing ffice space, use f emplyees r cmmingling f affiliated r related peratins r services f any kind? If yes, please prvide an explanatin in the area belw. 5. Is the applicant, r any affiliated, related predecessr entity currently invlved in any litigatin, administrative r arbitratin prceeding(s) r subject t any curt r agency rder r injunctin? If yes, please prvide an explanatin in the area belw. 6. Has the applicant, r any affiliated, related predecessr entity ever been (r currently is) the subject f bankruptcy, rerganizatin, slvency, disslutin r ther debtr related prceedings and/r has made assignment fr the benefit f creditrs? If yes, please prvide an explanatin in the area belw. CONTRACTORS AND CONSULTANTS APPLICATION Page 1 f 5

2 4. Is the applicant a successr f any ther business? If yes, please list predecessr in the area belw. 7. Has the applicant, r any affiliated, related predecessr entity r any fficer r wner ever been cnvicted f a crime? If yes, please prvide an explanatin in the area belw. 8. If yu answered yes t any f the questins listed abve, please include a detailed explanatin: D. PRIOR LIABILITY CARRIER INFORMATION (Past three years) 1. Cverage Frm Carrier 3. Receipts 4. Limit f Liability 5. Deductible 6. Type f Plicy Has any plicy r cverage been declined, cancelled and/r nn-renewed during the prir three years? (If yes, please explain): E. GROSS RECEIPTS 1. 1 st Prir Year: $ 2. 2 nd Prir Year: $ 7. Rate 8. Premium 3. 3 rd Prir Year: $ te: Grss Receipts are the ttal f all receipts, invices and/r billing withut any deductins f any kind. Please list yur estimated receipts including subcntracted wrk fr the next 12 mnths next t the apprpriate categry. List services nt described belw under Other (please be specific): 4. Cntracting 5. Cnsulting/Labratry Asbests Abatement $ Envirnmental Cmpliance $ Bi Remediatin $ Envirnmental Permitting $ Drilling (nt il/gas) $ Air Mnitring $ Emergency Respnse $ Envirnmental Sampling $ Haz Mat Clean Up $ Expert Witness $ Haz Mat Packing / Pickup $ Litigatin Supprt $ Lead Abatement $ Envirnmental Impact Studies $ Liquid Waste Remediatin $ Safety Training $ Abve Grund Strage Tank Installatin $ Undergrund Strage Tank Testing $ Abve Grund Strage Tank Remval $ Manual Preparatin $ Undergrund Strage Tank Installatin $ Phase I Envirnmental Assessments $ Undergrund Strage Tank Remval $ Phase II & III Envirnmental Assessments $ PCB Remval / Remediatin $ Remedial Investigatin / Studies $ Sil Remval / Remediatin $ Remedial Design $ Sil Excavatin ther than petrleum $ Remediatin Oversight $ Tank &/r Pipe Cleaning $ Analytical Labratries $ Wetlands Cntracting $ Haz Mat Cnsulting $ Mld Remediatin $ Mld Evaluatin / Cnsulting $ Fire / Water Restratin $ Civil Engineering $ Rfing $ Getechnical (i.e. fundatin, retaining wall, Carpentry $ slpe stability, etc.) $ Demlitin $ Gephysical (i.e. drilling, sampling, etc.) $ Plumbing $ Hydrgelgical Investigatins $ CONTRACTORS AND CONSULTANTS APPLICATION Page 2 f 5

3 Other Cntracting Wetlands $ Describe: $ Prject Management $ Describe: $ Other - Cnsulting / Labratry Describe: $ Describe: $ Describe: $ Describe: $ Ttal Prjected Cntracting Grss Receipts: $ F. SUBCONTRACTED SERVICES Ttal Prjected Cnsulting/ Labratry Grss Receipts: $ 1. Please identify the services that are subcntracted: 2. Applicable Cst: Descriptin: $ Descriptin: $ Descriptin: $ Descriptin: $ 3. Are all subcntractrs licensed and accredited? 4. Des the applicant cllect certificates f insurance frm all subcntractrs? 5. Are the subcntractrs required t name the applicant as an additinal insured? 6. Is a standard written cntract used with the applicant s clients and/r subcntractrs, including hld harmless and limitatin f liability clause? G. GENERAL INFORMATION 1. Des the applicant directly r indirectly perfrm wrk n residential prperties? 2. Are mre than 50% f the applicant s services subcntracted? 3. Is the applicant applying fr prject specific cverage? If yes, please attach a cpy f the cntract fr the prject and prject supplemental applicatin. 4. Are any f the applicant s revenues generated by cntracting services perfrmed in New Yrk City? 5. Des the applicant cnduct tank installatin wrk? b) Are the installed tanks precisin tightness tested befre being released t wner? c) Des the applicant apply any type f crrsin prtectin? d) Are tanks tested and certified by a registered prfessinal befre use? Please submit the fllwing: Resumes and certificatins f all tank installatin emplyees, type f tanks applicant installs, type f crrsin prtectin applicant installs & installatin prcedures. 6. Des the applicant install any type f liner, i.e. landfill, lagns, etc.? Please submit the fllwing: Resumes and certificatins f emplyees installing the liners, installatin prcedures & testing prcedures fr the installed liner. 7. Des the applicant cnduct mre than 10% getechnical r gephysical peratins? CONTRACTORS AND CONSULTANTS APPLICATION Page 3 f 5

4 Please submit the fllwing: A detailed list f the applicant s getechnical and gephysical peratins & detailed resumes f emplyees wh cnduct these peratins. 8. Des the applicant cnduct any Phase I r Real Estate Transfer Assessments? b) Des the applicant fllw ASTM-1527 guidelines? If n, please attach a sample cntract f the applicant s frmat. G. GENERAL INFORMATION (cntinued) 9. Des the applicant cnduct any type f mld cntracting r mld cnsulting wrk? If yes, please cmplete and attach a Supplemental Mld Cntractrs and Cnsultants Applicatin. If n, but the applicant is interested in being cnsidered fr claims-made mld cverage fr claims that may arise frm the applicant s cntracting peratins, please cmplete and attach a Supplemental Mld Applicatin. 10. Ttal persnnel (List each persn nly nce, by primary functin): a) Architects, Engineers, Gelgists, Hydrgelgists b) Industrial Hygienists, Txiclgists, CIHs r CSPs c) Supervisrs/Fremen/Leadmen d) Draftsmen, Technicians e) Labrers f ) AHERA, Hazwpers g) Other (please specify primary functin and cunt per primary functin): 11. Has any claim, suit r ntice f incident been made against the firm r any staff member? If yes, please prvide full details n each incident: 12. Is the applicant aware f any circumstances, which may result in any claim, suit r ntice f incident against him, the firm, his predecessrs in business, any f the present r past partners r fficers, r any staff member and/r has any claim, suit r ntice f incident been made against the firm r any staff member? If yes, please prvide full details n each incident: FRAUD WARNING: APPLICABLE TO ALL STATES Any persn wh knwingly and with intent t defraud any insurance cmpany r ther persn files an applicatin fr insurance r statement f claim cntaining any materially false infrmatin, r cnceals fr the purpse f misleading, infrmatin cncerning any fact material theret, cmmits a fraudulent insurance act, which is a crime and shall als be subject t a civil penalty nt t exceed five thusand dllars and the stated value f the claim fr each such vilatin. WARRANTY STATEMENT The undersigned authrized fficer f the applicant declares that the statements set frth herein are true. The undersigned authrized fficer agrees that if the infrmatin supplied n the applicatin changes between the date f the applicatin and the effective date f the insurance, he/she (undersigned) will immediately ntify the insurer f such changes, and the insurer may withdraw r mdify any utstanding qutatins and/r authrizatin r agreement t bind the insurance. Signing f this applicatin des nt bind the applicant t the insurer t cmplete the insurance. CONTRACTORS AND CONSULTANTS APPLICATION Page 4 f 5

5 NOTICE TO APPLICANTS: Any persn wh knwingly and with intent t defraud any insurance cmpany r ther persn files an applicatin fr insurance cntaining any false infrmatin, r cnceals fr the purpse f misleading, infrmatin cncerning fact material theret, cmmits a fraudulent insurance act, which is a crime. Signature: Print Name: Title: Date: CONTRACTORS AND CONSULTANTS APPLICATION Page 5 f 5