Workers Compensation Questionnaire- Brochure

LIABILITY INSURANCE QUESTIONNAIREPlease return this form by fax, mail, or email.1. Applicant’s Name:2a. Principal Business Address:2b. City, State, Zipcode:3. E-mail:4. Website (www.yourwebsite.com):5. FEIN#: 6. Number of Years in Operation:7. Type of business: Corporation Partnership Individual LLC8. Is the firm engaged in, owned by, associated with, or controlled by any other business? Yes NoIf “yes,” please explain. 9. Describe your operations fully (attach separate sheet if necessary):10. Describe your subcontracted operations:11. What is the estimated annual cost of subcontracted operations? 12. Do you require your subs to carry their own insurance? Yes NoI n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms1 of 3If yes, what types of insurance do you require? 13. Number of employees (including owners): 14. Total payroll:15. PRIOR & CURRENT GENERAL LIABILITY INFORMATIONName of Company Limit of Liability ($) Claims Made/Occurrence Premium ($) Expiration DateRetroactive Date12316. PRIOR & CURRENT PROFESSIONAL / CONTRACTOR’S POLLUTION LIABILITY INFORMATIONName of Company Limit of Liability ($) Claims Made/Occurrence Premium ($) Expiration DateRetroactive Date12317. List any claims or occurrences threatened, defended, or settled in the past five years and any settlement amounts:18. Please provide the following information on annual gross receipts:Projected Receipts Next 12 Months Receipts Previous YearAsbestos/Lead Abatement Asbestos/Lead Testing/ConsultingDemolitionEnvironmental ConsultingExpert WitnessGroundwater RemediationHaz Mat Package/Pick-up Health & Safety ConsultingLead Paint AbatementMicrobial AbatementMicrobial Test/ConsultingOwned LaboratoriesI n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms2 of 3(continued) Projected Receipts Next 12 Months Receipts Previous YearPhase I/Site AssessmentsPhase II Site SurveyRemediation DesignStorage Tank TestingToxicologyUST/Soil RemediationWastewater treatmentOther (describe)19. Indicate the desired coverages, limits, and deductibles:19a. General Liability: Yes No19b. Professional Liability: Yes No19c. Pollution Liability: Yes No20. Limits of Liability:$ 1,000,000 per occurrence / $ 1,000,000 aggregate $ 1,000,000 per occurrence / $ 2,000,000 aggregate$ 2,000,000 per occurrence / $ 2,000,000 aggregate $ 5,000,000 per occurrence / $ 5,000,000 aggregateDeductible:Additional information requested – Please send the following:1. Key Person Resumes – Statement of Qualifications or Web-Site Reference2. Certifications / Licenses of Key Employees if resumes with this information are not included3. Most Recent Year End Financials and Interim Financials4. Sample Client Service Agreement5. Sample Sub-Contractor Agreement6. Quality Control Manuals7. Promotional / Advertising MaterialI CERTIFY THAT THE STATEMENTS ABOVE ARE CORRECT AND TRUE.Signature over printed name of person completing questionnaire:Phone Number (ex: 000-000-0000): Date (mm/dd/yyyy):I n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms3 of 3 1 Applicants Name: 2a Principal Business Address: 2b City State Zipcode: 3 Email: 4 Website wwwyourwebsitecom: 5 FEIN: 6 Number of Years in Operation: Type of Business: 8 Is the firm engaged in owned by associated with or controlled by any other business: If yes please explain: 9 Describe your operations fully attach separate sheet if necessary: 10 Describe your subcontracted operations: 11 What is the estimated annual cost of subcontracted operations: 12 Do you require your subs to carry their own insurance: If yes what types of insurance do you require: 13 Number of employees including owners: 14 Total payroll: Name of Company1: Limit of Liability 1: Claims Made Occurrence1: Premium 1: Expiration Date1: Retroactive Date1: Name of Company2: Limit of Liability 2: Claims Made Occurrence2: Premium 2: Expiration Date2: Retroactive Date2: Name of Company3: Limit of Liability 3: Claims Made Occurrence3: Premium 3: Expiration Date3: Retroactive Date3: Name of Company1_2: Limit of Liability 1_2: Claims Made Occurrence1_2: Premium 1_2: Expiration Date1_2: Retroactive Date1_2: Name of Company2_2: Limit of Liability 2_2: Claims Made Occurrence2_2: Premium 2_2: Expiration Date2_2: Retroactive Date2_2: Name of Company3_2: Limit of Liability 3_2: Claims Made Occurrence3_2: Premium 3_2: Expiration Date3_2: Retroactive Date3_2: 17 List any claims or occurrences threatened defended or settled in the past five years and any settlement amounts: Projected Receipts Next 12 MonthsAsbestosLead Abatement: Receipts Previous YearAsbestosLead Abatement: Projected Receipts Next 12 MonthsAsbestosLead TestingConsulting: Receipts Previous YearAsbestosLead TestingConsulting: Projected Receipts Next 12 MonthsDemolition: Receipts Previous YearDemolition: Projected Receipts Next 12 MonthsEnvironmental Consulting: Receipts Previous YearEnvironmental Consulting: Projected Receipts Next 12 MonthsExpert Witness: Receipts Previous YearExpert Witness: Projected Receipts Next 12 MonthsGroundwater Remediation: Receipts Previous YearGroundwater Remediation: Projected Receipts Next 12 MonthsHaz Mat PackagePickup: Receipts Previous YearHaz Mat PackagePickup: Projected Receipts Next 12 MonthsHealth Safety Consulting: Receipts Previous YearHealth Safety Consulting: Projected Receipts Next 12 MonthsLead Paint Abatement: Receipts Previous YearLead Paint Abatement: Projected Receipts Next 12 MonthsMicrobial Abatement: Receipts Previous YearMicrobial Abatement: Projected Receipts Next 12 MonthsMicrobial TestConsulting: Receipts Previous YearMicrobial TestConsulting: Projected Receipts Next 12 MonthsOwned Laboratories: Receipts Previous YearOwned Laboratories: Projected Receipts Next 12 MonthsPhase ISite Assessments: Receipts Previous YearPhase ISite Assessments: Projected Receipts Next 12 MonthsPhase II Site Survey: Receipts Previous YearPhase II Site Survey: Projected Receipts Next 12 MonthsRemediation Design: Receipts Previous YearRemediation Design: Projected Receipts Next 12 MonthsStorage Tank Testing: Receipts Previous YearStorage Tank Testing: Projected Receipts Next 12 MonthsToxicology: Receipts Previous YearToxicology: Projected Receipts Next 12 MonthsUSTSoil Remediation: Receipts Previous YearUSTSoil Remediation: Projected Receipts Next 12 MonthsWastewater treatment: Receipts Previous YearWastewater treatment: Projected Receipts Next 12 MonthsOther describe: Receipts Previous YearOther describe: General Liability: Professional Liability: Pollution Liability: Limits of Liability: Deductible: Phone Number ex 0000000000: Date mmddyyyy: Clear Form: