Chemical Engineer


Applicant Information (*required field)




please enter N/A, if none






Personnel

7. Number of Staff

Previous Year
Current Year
Previous Year
Current Year
Previous Year
Current Year
Previous Year
Current Year


7c. Please attach details of the Academic Qualifications of the Applicant’s Principals/Partners/Directors and Licensed Professionals. (Please attach resume and include detail of experience level on work you are currently performing).

Email requested document separately to aiche-questions@alliant.com

Gross Billings

Total Gross Billings for professional services (collected or not) to include reimbursable expenses and sub-consulting fees:



Professional Disciplines
Please include Description, overall percentage and years experience.


















































14. Please describe the Applicant’s 3 largest projects during the past 3 years.

15. Please attach a copy of the Company’s brochure, if available.

Email requested document separately to aiche-questions@alliant.com



17. Please attach a copy of a typical contract of hire utilized by the Applicant

Email requested document separately to aiche-questions@alliant.com

Subcontractors / Subconsultants








Management






Loss History






Insurance


22. Please give details of previous insurance:

Each Claim / Aggregate

Please check coverage Limits and Deductible requested:








Supplemental Policy




Submission

THE APPLICANT DECLARES THAT, AFTER INQUIRY, TO THE BEST KNOWLEDGE OF ALL PERSONS TO BE INSURED THE STATEMENTS SET FORTH HEREIN AND IN ANY ATTACHMENTS MADE HERETO ARE TRUE, AND NO MATERIAL FACTS HAVE BEEN SUPRESSED, OMITTED, OR MISSTATED. UNDERWRITERS RESERVE THE RIGHT TO AMEND THE TERMS, CONDITIONS AND LIMITATIONS OF ANY POLICY ISSUED AS A RESULT OF THIS APPLICATION, IF SUBSEQUENT TO THE DATE OF THIS APPLICATION, BUT PRIOR TO THE INCEPTION OF SUCH POLICY, THERE ARE ANY MATERIAL ALTERATIONS TO THE INFORMATION CONTAINED HEREIN. COMPLETION OF THIS APPLICATION DOES NOT BIND THE UNDERWRITER TO PROVIDE COVERAGE, BUT IT IS AGREED THAT THE STATEMENTS AND PARTICULARS CONTAINED HEREIN WILL BE RELIED UPON BY UNDERWRITERS IN THE EVENT A POLICY IS ISSUED. THIS APPLICATION IS SIGNED ON BEHALF OF ALL OWNERS, PRINCIPALS, PARTNERS, SHAREHOLDERS, DIRECTORS AND EMPLOYEES. BY SUBMITTING THIS APPLICATION, THE APPLICANT AGREES THAT IN THE EVENT THE APPLICATION CONTAINS MISREPRESENTATIONS OR FAILS TO STATE FACTS MATERIALLY AFFECTING THE RISK ASSUMED BY THE INSURING COMPANY UNDER A POLICY ISSUED, THE POLICY MAY BE DEEMED NULL AND VOID.

PLEASE NOTE: DUE TO STATE REGULATORY FILING REQUIREMENTS, PREMIUM PAYMENT & A SIGNED APPLICATION MUST BE RECEIVED BY THE EFFECTIVE DATE TO BIND COVERAGE.