Company Name:
Email:
Business License:
Business Phone:
Company Address:
City:
State:
Zip:
Nature of Business:
Business Type: Proprietorship    Corporation    Partnership    LLC   

Date Formed (Corp or LLC): / /
Number of Owners/Partners/Members:
How long in business?
Bank (Business Account):
Phone #:
Account #:
Balance:
Previous Bonding Company:
Reason for Changing Bonding Co.:

Asbestos Abatement Contracting:
Lead-Based Paint Abatement Contracting:
Crime Scene Cleanup Contracting:
Environmental Drilling (not oil/gas) Contracting:
Environmental Emergency Response Contracting - Spill Cleanup:
Hazardous Material Cleanup Contracting:
Hazardous Material Packing/Pickup Cleanup Contracting:
Illegal Drug Lab Contracting:
Groundwater Remediation Contracting:
Landfill Construction Contracting:
Liquid Waste Remediation Contracting:
Medical Waste Pickup Contracting:
PCB-Light Ballast Removal Contracting:
PCB-Removal/Remediation Contracting:
Radon Contracting:
Self-Remediation Contracting -- Bioremediation:
Self-Remediation Contracting -- Petroleum Contaminated Soil:
Self-Remediation Contracting -- Other than Petroleum Contaminated Soil:
Trucking -- Hazardous Material:
Waste Incineration:
Waste Water Treament System Install/Maintenance:
Wetlands Contracting:
Other (describe):         

Aboveground Storage Tank Installation Contracting:
Aboveground Storage Tank Removal:
Underground Storage Tank Installation Contracting:
Underground Storage Tank Removal:
Storage Tank & Pipe Cleaning Contracting:
Storage Tank & Part Sales Contracting:
Service Station Contracting (building, construction, concrete, electric):
Fuel System Equipment Installation Service & Maintenance (not tanks):
Other (describe):         

Mold Prevention Contracting:
Mold Remediation Contracting:
Mold, Fire, Water, or Storm Damage Restoration Contracting:
Water Extraction Contracting:
Other (describe):         

Build Back - Restoration:
Demolition - Interior Only:
Demolition - Over 2 Stories:
Drilling - Non-Environmental (not oil/gas):
Excavation:
Insulation Installation:
Trucking - Non-Hazardous Material:
Other (describe):         

Environmental Compliance:
Environmental Permitting:
Air Monitoring:
Environmental Sampling:
Environmental Expert Witness:
Environmental Litigation Support:
Wildlife Studies:
Environmental Impact Studies:
Safety Training:
Environmental Manual Preparation:
Indoor Air Quality Consulting:
Industrial Hygiene/Health and Safety Consulting:
Phase I Environmental Site Assessments:
Phase II Environmental Site Assessments:
Phase III Environmental Site Assessments:
Environmental Remedial Investigation/Studies:
Environmental Feasibility Studies:
Hazardous Materials Consulting:
Underground Storage Tank Testing:
Environmental Laboratories:
Wetlands Consulting:
Geotechnical Consulting:
Geophysical Consulting:
Radon Testing:
Other:
Trucking - Non-Hazardous Material:
Other (describe):         

Air Monitoring for Mold:
Indoor Air Quality Consulting - Mold:
Mold Inspection:
Mold Remediation Plan Design:
Post Mold Remediation Testing & Consulting:
Laboratory Analysis of Mold:
Other (describe):         

Subcontractors / Subconsultants / Independent Contractors:

Please identify the services that are performed on your behalf by others UNDER written contract:

Please identify the services that are performed on your behalf by others WITHOUT a written contract:

Liability Limit Request:

Hold Harmless and Indemnification Clause in your favor Detailed Scope of Services Clause Requirement that you be named as an Additional Insured on their CGL Policy Requirement that you be granted a Waiver of Subrogation on their CGL Policy

Describe the Minimum Insurance Requirements of your Subconsultants/Subcontractors/Independent Contractors:
Commercial General Liability:
Contractors Pollution Liability:
Professional Liability:
Do you require proof of Workers Compensation coverage from all Subconsultants/Subcontractors/ Independent Contractors? Yes   No
Does your firm collect Certificates of Insurance from All Subcontractors? Yes   No

Do you use a standard indemnity contract with all of your clients? Yes   No
If not, please detail your contract procedures:



Do you loan, lease or rent equipment to others? Yes   No
If yes, describe the equipment:
What percentage of your overall sales are associated with this operation:

Do you install any type of liner, i.e. landfill, lagoons, etc.? Yes   No
If yes, what percentage of your overall sales are associated with this operation:

Do you operate an in-house laboratory? Yes   No
If yes, what percentage of your overall sales are associated with this operation:

Do you conduct any type of geotechnical operations? Yes   No
If yes, what percentage of your overall sales are associated with this operation:

Do you conduct any Phase I or Real Estate Transfer Assessments? Yes   No
If yes, what percentage of your overall sales are associated with this operation:
Do you follow ASTM-1527 guidelines? Yes   No

Has any claim, suit or notice of incident been made against the firm or any staff member? Yes   No
If yes, please describe:


Is the applicant aware of any circumstances which may result in any claim, suit or notice of incident against him, the firm, his predecessors in business, any of the present or past partners or officers, or any staff member? Yes   No
If yes, please describe: