• 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?