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Application for Engineers Professional Liability Insurance

 
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Please Note:   If you are requesting a quote for Professional Liability renewal, we can quote off your renewal application from your current carrier. Please fax to us at: (512) 330-9856

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:
  1. Current claims history/Insurance Company loss summary for the past five years.
  2. Resumes of key licensed design professionals on staff.
  3. List of five largest projects over the past three years.
  4. 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.

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