Application for Engineers Professional Liability Insurance
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prior to filling out the form online. Any information you input will be lost if you close your browser or navigate to another page or website prior to
submitting your information by pressing the "Submit" button at the bottom of this form.
General Information
Name of Firm:
Date Established:
Address:
City/State/Zip:
Branch Office Address(es):
Phone:
Website:
Contact Name:
Email Address:
Firm is:
Personnel
Specify personnel per categories below:
Number:
Full-Time:
Part-Time:
Principals, Partners, Officers & Directors:
Architects:
Engineers:
Land Surveyors:
Technical Personnel:
Others (administrative/clerical):
Total Personnel:
Gross Receipts
Gross receipts to include reimbursable expenses and fees paid to subconsultants. Current fiscal year ends:
Gross Receipts attributable to:
Last Fiscal Year Ending:
Two Years Ago Ending:
Separately insured projects:
$
$
Total Gross Receipts:
$
$
Estimated Total Gross Receipts for next fiscal year:
$
Professional Disciplines
Specify as a percentage of the firm's gross receipts. Total should equal 100%:
Architecture:
%
Landscape Architecture:
%
HVAC Engineering:
%
Civil Engineering:
%
Land Surveying:
%
Fire Protection Engineering:
%
Mechanical Engineering:
%
Construction/Project Management:
%
Construction Materials Testing:
%
Electrical Engineering:
%
Process Engineering:
%
Mining Engineering:
%
Structural Engineering:
%
Chemical Engineering:
%
Interior Design:
%
Soils Engineering:
%
Environmental:
%
Land Use Planning:
%
Laboratory Testing:
%
Hydrogeology/Geology:
%
Design/Build:
%
Soils/Geotechnical Engineering:
%
Other:
%
Grand Total Percentage:
%
Services
Percent gross receipts (must total 100%)
Design/Studies:
Design with construction observation/review:
%
Design without construction observation/review:
%
Studies, planning, permitting:
%
Construction Related Services:
Construction Management Services (Agency):
%
Construction Management Services (At risk):
%
Project Management:
%
Construction observation/review without design:
%
Surveying:
Construction Staking:
%
Topographic/Boundary Surveys:
%
Other:
%
Inspections as Stand-Alone Service:
Construction Inspection:
%
Real Estate Pre-Acquisition:
%
Mold Inspection/investigation:
%
Water Intrusion inspection:
%
Miscellaneous Services:
Forensic/Expert Witness:
%
Plan Checking:
%
Quantity/Cost Estimating:
%
Drafting (stand alone service without design):
%
Other:
%
Grand Total Percentage:
%
Clients
Percent of Clients (must total 100%)
Government or Public Entities:
%
Owners acting as their own builders:
%
Design/Build or turnkey contractors:
%
Other contractors:
%
Developers:
%
Financial and lending institutions:
%
Other design professionals:
%
Insurance Companies/Attorneys:
%
Other:
%
Grand Total Percentage:
%
Projects
As a Percent of Gross Receipts (must total 100%)
Schools, colleges:
%
Hospitals, retirement or convalescent homes:
%
Hotels, motels or resort properties:
%
Condominiums/Townhouses:
%
Residential subdivisions/Tract Homes:
%
Custom single family residential:
%
Remodel only - single home:
%
Apartments:
%
Office/Commercial/Retail:
%
Government/Public Buildings:
%
Industrial Process:
%
Machine design:
%
Sports Stadiums/Amusement Parks:
%
Public Utilities/Power Generation:
%
Jails/Justice:
%
Airports:
%
Roads/Highways/Traffic:
%
Sewage or waste disposal systems:
%
Water systems:
%
Wastewater Treatment Plants:
%
Pipelines:
%
Petro Chemical (oil & Gas) other than pipelines:
%
Dams/reservoirs/mines/quarries:
%
Harbors, jetties, docks or piers:
%
Bridges, trestles or tunnels:
%
Parking Garages/Theaters/ Convention Centers:
%
Falsework/Shoring/Temporary Structures:
%
Other:
%
Grand Total Percentage:
%
In the past 5 years has your firm, a predecessor firm or any other insured provided any services on residential condominium or townhouse projects?:
Yes
No
If yes, please provide details:
If yes, what are the total number of Condominium/Townhouse Projects?:
If yes, what is the approximate total construction value?:
$
What percentage of the firm's projects are done on a Fast Track Basis?:
%
What percentage of the firm's projects are outside the U.S. and Canada?:
%
Which countries? (list):
Contracts
Please specify types of contract used by the firm (must total 100%)
Standard industry contract (AIA, EJCDC, ASFE, etc.):
%
Firm's own standard contract:
%
Letter agreement:
%
Purchase order:
%
Client contract:
%
Oral agreement:
%
Other:
%
Grand Total Percentage:
%
What percentage of the firm's contracts contains a Limitation of Liability clause?:
%
Financial and Other Interests
Does the firm have any predecessor firms or related entities?:
Yes
No
If yes, list all pre-existing entities, including mergers and their dates of existence below:
During the past 12 months has the firm or any principal...
...Engaged in actual construction or hired a construction contractor to perform construction work?: (If "Yes", please provide details below)
Yes
No
...Become involved with or have ownership interest in a construction or real estate development company?: (If "Yes", please provide details below)
Yes
No
...Been employed by or an officer of any other firm, organization or political body?: (If "Yes", please provide details below)
Yes
No
...Derived more than 60% of last fiscal year's gross receipts from any one client?: (If "Yes", please provide details below)
Yes
No
...Designed a building, component or system which might be used on more than one project?: (If "Yes", please provide details below)
Yes
No
...Become involved in the manufacture or fabrication of any component, device or system?: (If "Yes", please provide details below)
Yes
No
...Provided electronic date processing services for others or sold software components?: (If "Yes", please provide details below)
Yes
No
...Been the subject of disciplinary action by authorities as a result of professional or business activities?: (If "Yes", please provide details below)
Yes
No
Has the firm entered into any Joint Ventures?:
Yes
No
Does the firm's Joint Venture agreement provide for allocation of liabilities?:
Yes
No
Does the firm require evidence of professional liability insurance from all Joint Venture members?:
Yes
No
Does your firm or any principal, partner, officer, director or shareholder of your firm or any immediate family member of any such person have an ownership interest in any entity or project for which professional services have been or are to be rendered?:
Yes
No
Other than for third party claims, does your firm seek coverage for these projects?:
Yes
No
If yes, an Equity Interest Supplemental Application must be submitted.
Subcontractors / Subconsultants
Please provide, as a % of the Total Gross Receipts reported in Gross Receipts section above, the fees paid to the firm's subconsultants in the following disciplines (Should not total 100%)
Architecture:
%
Soils:
%
Civil:
%
Structural:
%
Mechanical:
%
HVAC:
%
Electrical:
%
Other:
%
Grand Total Percentage:
%
Describe the firm's subcontractor and subconsultant selection process:
Do you hire subcontractors to perform construction?: (If "Yes", please explain below)
Yes
No
Are all subcontractors and subconsultants hired under a written contract?:
Yes
No
Does the firm obtain certificates of insurance from all subcontractors and subconsultants?:
Yes
No
QA / QC Issues
Does the firm have an Ownership of Documents clause in each contract of hire?:
Yes
No
If "No", what does the firm do to protect itself against reuse of its plans and specifications without knowledge or authorization?:
Does the firm have a written Quality Assurance/Quality Control Program?:
Yes
No
Does a principal check all plans before they are sent to the field?:
Yes
No
Does the firm have an in-house program of continuing education for professional employees?:
Yes
No
Has the firm participated in an Organizational Peer Review in the past five years?:
Yes
No
Please list all professional societies or associations to which the firm or members of the firm belong:
Liability Issues
Have any Professional Liability claims been made against the firm or any of its members?:
Yes
No
Does the firm or any of its members have any knowledge of prior acts, errors or omissions which might reasonably be expected to give rise to a claim under this insurance?: (If "Yes", please provide details below)
Yes
No
Does the firm or any of its members have knowledge of any deficiencies, property damage or bodily injury whether actual or alleged, in connection with projects for which the firm has performed professional services?: (If "Yes", please provide details below)
Yes
No
Does the firm have any pending dispute concerning the payment of fees to the firm for services rendered?: (If "Yes", please provide details below)
Yes
No
Does the firm or any of its members have any knowledge of any circumstance, incident, situation, accident condition or unresolved job controversy or other matter which might have rise to a claim under this insurance?: (If "Yes", please provide details below)
Yes
No
Has the firm or any of its members testified, provided expert testimony or given a deposition or statement in any disputes or proceedings where claim has been made or suit filed against any party to the work or project where the firm provided professional services?: (If "Yes", please provide details below)
Yes
No
Has the firm or any of its members given notice to any other Professional Liability underwriter or any actual or alleged act, error, omission, deficiency, property damage or bodily injury, circumstance, incident, situation, accident, unresolved job controversy or fee dispute which could result in a claim?:
Yes
No
Insurance History
Has any insurer cancelled or refused to renew any similar insurance issued to the firm or any of its members?: (If "Yes", please provide details below)
Yes
No
Are you currently insured under a Professional Liability Policy?:
If "Yes", please detail below Professional Liability insurance for past 5 yrs.
Yes
No
COMPANY
TERM
LIMIT
DEDUCTIBLE
PREMIUM
Please answer one of the two following questions (*required)
Check here if you do NOT have a current policy or enter retroactive date on current policy below:
No Current Policy
Retroactive date on current policy:
Please provide below current General Liability policy information:
COMPANY
TERM
LIMIT
DEDUCTIBLE
PREMIUM
Is your firm currently insured under a separate, Project Specific professional liability policy?:
If yes, provide a copy of the Declarations and answer the following below:
Yes
No
Project Name
Fees
Insurer
Limit/ Deductible
Policy Term
Ext Reporting Period (months)
Required Additional Information (must be submitted)
Please submit the following information along with this application:
Current claims history/Insurance Company loss summary for the past five years.
Resumes of key licensed design professionals on staff.
List of five largest projects over the past three years.
Firm's brochure or website address ( ).
The firm would like a quotation based on the following limit(s) and deductible(s):
Limit
Deductible
Additional Firm Information
List all predecessor Firms:
Name of Former Firm
Date of Existence
Reason for Change
Please provide any additional info regarding the firm and its services that you wish us to consider:
The applicant has read the foregoing and understands that completion of this Application does not bind the Underwriter or the Broker to provide coverage. It is agreed, however, that this Application is complete and correct to the best of applicant's knowledge and belief and that all particulars which may have a bearing upon acceptability as a Professional Liability insurance risk have been revealed. It is understood that this Application shall form the basis of the contract should the Underwriter approve coverage and should the applicant be satisfied with the Underwriter's quotation.
It is further agreed that, if in the time between submission of this Application and the requested date for coverage to be effective, the applicant becomes aware of any information which would change the answers furnished in response to questions in the Liability Issues section, or any other question of this Application, such information shall be revealed immediately in writing to the Underwriter.
Must be signed by Owner, Partner, or Officer.
Type Your Name
Title
Date
____________________________________________________
Signature of Applicant
Important: Please click on the Print Application button prior to the Submit Application button. You will need to sign the printed copy and then mail it to us. You should also keep a copy of this application for your records to use as a reference for your renewal.
Check Here:
I acknowledge that the information I am providing in this submission is true and accurate to the best of my knowledge.
