APPLICATION FOR ENVIRONMENTAL CONSULTANTS
PROFESSIONAL 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:

			
	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.
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 the underwriting manager, Company and/or affiliates thereof.

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.