ANCO Insurance: Special Programs - Land Surveyors / Engineers Program Application

Land Surveyors / Engineers Package Liability
Insurance Application

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.

		This Online Application is on a Secure Server. Click on the seal on the left for more information on the certificate's authentication.
Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.

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 you work out of your 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: $

Have you had
continuous coverage for
the 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:

How many years experience has management
had in the industry?

Please provide details as to type of experience:

What are the annual gross sales?

$
(Project next 12 months if you are new in 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

Have you had continuous Workers' Comp coverage for the past 3 years?

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


Have you had continuous coverage for the past 3 years?			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
* 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:

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.

CHECK HERE:

I acknowledge that the information I am providing in this submission is true and accurate to the best of my knowledge

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.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

then

"Endorsed by Texas Society of Professional Surveyors"