Application for Engineers Package Liability Insurance
Please Note: It is highly recommended that you read and/or print this form in its entirety and gather materials or information for your responses
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
*Required Field
Company Name:*
Business Type:*
Contact Name:*
Phone #:*
Fax:
Email Address:*
Mailing Address:*
City:*
State:*
Zip:*
Year Business Started:*
Federal ID #:*
(Please enter Soc. Sec. # if Sole Proprietor)
Proposed Effective Date:*
Description of Operations:*
Package Policy (General Liability and Property)
*** Coverage for Equipment ***
In order to quote coverage for equipment, please attach a schedule including make, model, year, vin # and cost of each item new.
Physical Address:
City:
State:
Zip:
County:
# of Stories in Building:
Are You in the City Limits?
Yes
No
If no, what fire dept responds?:
Year Building Built:
If over 25 yrs, list years and extent of updates to wiring, plumbing, roof below:
Square Footage You Occupy:
Do You Have a Central Station Alarm?
Yes
No
Construction of Bldg:
If Other:
Replacement Cost of Building if owned by you:
$
(don't include if work out of home)
Replacement Cost of Office Contents:
$
Equipment/Contents used off premises:
Cost if Brand New
Present Value
$
$
(don't include these values in contents limit above)
Do you use watercraft in your business?
Yes
No
Is your equipment ever waterborne?
Yes
No
If "yes", value: $
Continuous coverage for past 3 years?
Yes
No
If YES,
With Whom:
Policy#:
Have you had any claims in the last 3 years?
Yes
No
Liability Limits Desired:
Years experience management has in industry:
Please provide details as to type of experience:
What are the annual gross sales?
$
(Project next 12 months if new business)
What is annual payroll & number of employees?
$
Employees:
Check if you need coverage for:
Additional Insureds
Waivers of Subrogation
Do you do oil/gas work?
Yes
No
If yes, what percentage of receipts?:
%
Are you using drones?
Yes
No
Workers' Compensation
*** Estimated Payroll for upcoming 12 months ***
Please Note: The maximum payroll to include is:
$43,800 for self employed (Sole Proprietors)
$62,400 for Executive Officers
Surveyors:
$
# of Employees:
Engineers:
$
# of Employees:
Executive Officers Who Don't Work in Field:
$
# of Employees:
($62,400 is maximum salary used for rating)
Clerical Employees:
$
# of Employees:
Other Employees:
Job Description(s) of other Employee(s):
$
# of Employees:
Executive Officer(s) Information
Name
Title
% Ownership
Payroll
$
$
$
$
$
Do you have any:
(Check if applys)
Waivers of Subrogation
Continuous Workers' Comp coverage past 3 yrs?
Yes
No
If "Yes", please answer next question below
Name of Carrier:
Policy Number:
Have you had any claims in the last 3 years?
Yes
No
Liability Limits Desired:
Are the owners covered by health insurance?:
Yes
No
Commercial Auto Insurance
(Please Note: If you use your own personal auto, you do not need to provide commercial auto insurance information.)
Limits desired:
(Please make a selection)
Vehicle Information
Year
Make
Model
VIN Number
Cost New*
Deductibles** Comp/Collision
County
Auto #1
$
$/
$
Auto #2
$
$/
$
Auto #3
$
$/
$
Auto #4
$
$/
$
Auto #5
$
$/
$
Driver Information
Driver Name
Date of Birth
State Licensed
Drivers License #
Driver #1
Driver #2
Driver #3
Driver #4
Driver #5
Continuous coverage for the past 3 years?
Yes
No
If "Yes", please answer next question below
Name of Carrier:
Policy Number:
Any claims in the last 3 years?
Yes
No
* What the vehicle cost new is only required if you want full coverage
(physical damage) on the auto. Even if you bought used, estimate cost new.
** If you only want liability coverage, mark "N/A".
Commercial Umbrella
Limits requested:
Other Amount:
$
Additional Comments
Please give any additional comments you feel appropriate
for this quotation. If you have additional information where
there was not enough fields above, please enter them here.
Submission Info
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 Underwriters quotation.
Your Name:
Your Title:
Date:
PLEASE DO NOT SUBMIT this application unless you have
completed the General Information section at the top of this form.
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.
