Environmental

Environmental Quote

General Information:
Named insured:
Address:
City:
State:
Zip:
Requested effective date:
Do you currently carry Professional Liability coverage?	No	Yes	Retroactive Date:
Do you currently carry Contractors Pollution Legal Liability Coverage?	No	Yes	Retroactive Date:
	Claims Made	Occurrence	Retroactive Date:
How long has the named insured been in business?
During the past five years has the name of the applicant been charged or has any other business been purchased or have any mergers or consolidations taken place (please check):	No	Yes	If yes, please give full details:
Total professional staff personnel of named insured:	Principals		Hydrogeologists, geologists, chemists
	Supervisors/foreman		Others
	Engineers & Architects		Total number of employees

Projected Total Gross Receipts
Total Receipts: $
Receipts Breakdown-(in dollars)
Environmental Consulting
Environmental Contracting
Phase 1's
Non-Environmental Engineering
Non-Environmental Construction
Receipts Not Otherwise Classified
Please include, on a separate page, a breakdown by sales and a description of all non-environmental and not otherwise classified receipts.

Transportation
Does your company select or arrange for the site of disposal for hazardous or non hazardous waste on behalf of clients?	No Yes
Does your company own, operate or lease licensed waste treatment, storage or disposal facilities?	No Yes
Does your company transport hazardous or non hazardous waste in company or employee owned vehicles?	No Yes

Contractual
Are updated certificates of insurance from subcontractors kept on file?	No Yes
Are these certificates required to show pollution liability insurance?	No Yes
What are the minimum limits of liability you require for your subcontractors?	General Liability: $
	Pollution Liability: $
	Professional Liability: $
Do you require subcontractors' policies to name you as an additional insured?	No Yes
Do your contracts with subcontractors contain an indemnification provision? If yes, please attach copies of all insurance requirements and indemnification clauses.	No Yes
Does your company enter into written contacts where you assume liability? If yes, please attach copies of all insurance requirements and indemnification clauses.	No Yes

Loss History
Is the Named Insured or any employee aware of any fact, circumstance or situation that could result in a claim being made against the Named Insured or any other person of entity for whom coverage will be sought?	No
	Yes
	If yes, give full details:
Have any claims previously been made against the Named Insured or reported under any other General Liability Contractor's Pollution or Professional Liability Policies?	No Yes
If yes, attach a separate sheet explaining 1). the date when claim was made; 2). the date of the incident, act or omission giving rise to the claim; 3). name of the claimant; 4). nature of the claim; 5). amount paid or estimated may be paid; and 6). final disposition or current status.

Required Attachments: (Please check to be sure you included it); Resumes of all professional staff and job site supervisors. An explanation of all non-environmental receipts and not otherwise classified receipts and details of any losses that have occurred as required in question 20 above.
The applicant represents that the above statements and facts are true and that no materials facts have been suppressed or misstated.

Applicant:	Date:
Applicant: (Printed Name & Title)