Ill. Admin. Code tit. 35, pt. 740, subpt. I, app B
* Firm name.
* Address.
* Telephone/fax.
* Principal officials and titles.
* Number of full-time employees.
* Business structure (corporation, partnership, LLP, LLC, PSC).
* Licensed by Secretary of State? #___________
* Licensed by Dept. of Professional Regulation? #___________
* Name of Illinois Registered Managing Agent.
Names of insurance carriers and amount of coverage:
Worker's Compensation:_____________________________________________
General Liability:___________________________________________________
Professional Liability:________________________________________________
* Does the stated professional liability policy include coverage for "environmental" claims related to release of pollutants? If not covered, or covered by a different carrier or in a different amount, so state.
* Has the firm or owners ever filed bankruptcy? If "yes," state when and explain.
* Is the firm an outgrowth, result, continuation or reorganization of a former business? If "yes," explain background.
* List RELPEs and other key full-time employees that will participate on this project with the RELPE. Provide resumes for each, including Illinois P.E. License #, certifications, project role, years of experience in related work and education.
* List five projects similar in nature and identify the role of the RELPE.
* Are employees to be assigned to the project in compliance with 29 CFR 1910.120 (HAZWOPER training and medical surveillance) as applicable to their role on the project?
Ill. Admin. Code tit. 35, pt. 740, subpt. I, app B