Environmental CGL
Environmental commercial general liability insurance application form
Broker Information
Broker Name
*
First Name
Last Name
Broker Email Address
*
example@example.com
Broker Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Brokerage Name
Application Information
Applicant Name
*
First Name
Last Name
Applicant Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long has the Applicant been in business?
Number of employees?
Please list the details of all partners/directors
Please specify the total number of staff & per role
Rows
Number of staff
Professional Engineers
Environmental Scientists
Geotechnical Personnel
Project Managers
Environmental Engineers
Industrial Hygenist
Geology/Hydrologist
Field Personnel
Other Personnel
Total number of Staff
Back
Save & Exit
Next
Coverage Requested
Limit of Liability:
$1,000,000 / $1,000,0000
$3,000,000 / $3,000,0000
$4,000,000 / $4,000,0000
$2,000,000 / $2,000,0000
$5,000,000 / $5,000,0000
Other
Deductible Requested
$5,000
$10,000
$15,000
$25,000
$50,000
Other
Does the Applicant currently have professional liability insurance?
Yes
No
Insurer:
Renewal Date:
Limit of Liability
Deductible:
Retroactive Date:
Back
Save & Exit
Next
Services
Please describe the products and services supplied by the Applicant:
Estimated Annual Gross Revenues
Please indicate the projected revenue of Environmental Professional Services:
Please indicate the projected revenue of Environmental Professional Services:
Rows
Projected Revenue
Air Quality Testing & Consulting (Indoor Air Quality)
Air Quality Testing & Consulting (excluding Indoor Air Quality)
Environmental Compliance
Environmental Expert Witness
Environmental Feasibility Study
Environmental Impact Study
Environmental Laboratories
Environmental Litigation Support
Environmental Manual Preparation
Environmental Permitting
Environmental Remedial Investigation/Studies
Environmental Sampling
Hazardous Material Consulting
Inspection, Testing & Consulting – Asbestos
Inspection, Testing & Consulting – Lead
Inspection, Testing & Consulting – Mould
Inspection, Testing & Consulting – Other
Phase I Environmental Site Assessments
Phase II Environmental Site Assessments
Phase III Environmental Site Assessments
Water Quality Testing & Consulting (Potable)
Water Quality Testing & Consulting (excluding Potable)
Wetlands Consulting
Wildlife / Ecological Studies
Other Environmental Consulting - Describe
Please indicate the projected revenue of Non-Environmental Professional Services
Rows
Projected Revenue
Architecture
Construction Management
Chemical Engineering
Electrical Engineering
Geotechnical Consulting
HVAC Engineering
Industrial Engineering
Industrial Hygiene / Health & Safety Consulting
Land Surveying
Mechanical Engineering
Non-Destructive Testing (Aboveground Storage Tanks)
Non-Destructive Testing (Pipelines)
Non-Destructive Testing (Underground Storage Tanks)
Process Engineering
Septic System Design
Storage Tank System Design & Installation (Aboveground)
Storage Tank System Design & Installation (Underground)
Storage Tank System Removal (Aboveground)
Storage Tank System Removal (Underground)
Structural Engineering
Other Non-Environmental Consulting - Describe
Back
Save & Exit
Next
Additional Information
Please specify the percentage breakdown of revenue by client type
Rows
Percentage of Revenue by Type
Residential
Institutional
Responsiveness
Healthcare
Commercial
Industrial
Governmental
Please specify the percentage of the territorial breakdown
Rows
Percentage of Revenue by Territory
Canada
United States:
Other (specify)
Please list the Applicant’s three (3) largest projects (current or complete) during the last thirty-six(36) months
Please specify the percentage breakdown of jobs performed under the following types of agreements:
How are non-standard client or subcontract agreements reviewed?
Attorney: Outside
Attorney: In-House
Agent Reviews
Staff
Other
Do you employ subconsultants or contractors?
No
Yes
Please provide specifics
Are subconsultants or subcontractors hired under written contract?
No
Yes
Are subcontractors required to carry Professional Liability insurance?
No
Yes
Are subcontractors required to carry Pollution Liability insurance?
No
Yes
What are the minimum insurance limits required?
Back
Save & Exit
Next
Previous Claims Experience
If the Applicant answers "Yes" to any of the following questions, please provide additional details including a description of the situation, claim, or circumstance within the section provided or as an addendum to this application.
Are you aware of any facts or circumstances, during the past five (5) years, which may give rise to a claim under a policy which coverage is being sought?
Yes
No
Additional Details
Have any professional liability claim(s) been made against you, partner, executive officer, director, professional employee or any other employee in the past five (5) years?
Yes
No
Additional Details
THE UNDERSIGNED HEREBY ACKNOWLEDGES THE TRUTH OF THE STATEMENTS CONTAINED HEREIN.
I AUTHORIZE YOU TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION AS PERMITTED BYLAW, IN CONNECTION WITH YOUR COMMERCIAL INSURANCE POLICY OR A RENEWAL, EXTENSION ORVARIATION THEREOF, FOR THE PURPOSES NECESSARY TO ASSESS THE RISK, INVESTIGATE AND SETTLECLAIMS, AND DETECT AND PREVENT FRAUD, SUCH AS CREDIT INFORMATION, AND CLAIMS HISTORY
Signature of Applicant (authorized representative)
Confirm Form is Complete
Yes
Save
BOS JotForm Submission Key
BOS JotForm Redirection
Should be Empty: