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General Information
Your Name:
Date Licensed:
Home Mailing Address:
City:
State:	Zip:
County:
Phone:	Fax:

Gross Receipts Generated by You for Current Employer
	Current Year to Date	Last Year	Two Years Ago	Three Years Ago
Please  Identify  Year:
Gross  Receipts:	$	$	$	$
Estimated Gross Receipts generated by you for next fiscal year:				$
What percentage of Total Gross Receipts are derived from repeat clients:				%

Professional Disciplines
Specify as a percentage your work that is: Total should equal 100%
Land Surveying	Civil Engineering	Other		Total
%	%	%		%
Please describe your surveying services and the nature of the "other" services specified above:

Services
Enter the percentages of your generated receipts attributable to the following for the last year:
Service	Percent Gross Receipts (must total 100%)
Construction Staking:	%
Hydrographic Surveys:	%
Mapping:	%
Property Boundary Surveys:	%
Topographical Surveys:	%
Right-of-Way Surveys:	%
Aerial/Photogrammetry:	%
As-Built plats:	%
Studies/research:	%
Other:	%
Total:	%

Clients
Enter the percentages of your current employer's clients based upon the following professions/sectors:
Client Type/Profession	Percent of Clients (must total 100%)
Government or Public Entities:	%
Private - Owners:	%
Contractors:	%
Residential Developers:	%
Commercial Developers:	%
Financial Inst./Title Cos:	%
Industrial/Utilities:	%
Design Professionals:	%
Other:	%
Total:	%

Projects
Enter the percentages of your current employer's projects based upon the following categories:
Type of Project	Percent of Projects (based on receipts must total 100%)
Public Works/Infrastructure (roads, sewer, water, etc.):	%
Residential subdivisions:	%
Residential Condominiums/Townhomes:	%
Residential Apartments:	%
Residential / Private Homeowners:	%
Commercial/Retail:	%
Industrial/Pipelines:	%
Utilities:	%
Other:	%
Total:	%
Approximately what percentage of current employer's services are rendered on projects involving Bridges, Tunnels, Dams or Hazardous Waste sites?:	%
What percentage of current employer's projects are outside the U.S. and Canada?:	%

Projects II
Please list your 5 largest projects:
Proj. #1
Proj. #2
Proj. #3
Proj. #4
Proj. #5

Contracts
Enter the percentages of current employer's contracts based upon these contract forms:
Type of Contract	Percent of Contracts (must total 100%)
Standard Survey Organization contract (i.e. ACSM, NSPS, etc.):	%
Firm's own standard contract:	%
Letter agreement:	%
Purchase order:	%
Client contract:	%
Oral agreement:	%
Other:	%
Total:	%

Other Interests
What percentage of your current employers contracts contain a Limitation of Liability clause?:	%
Have you been the subject of disciplinary action by authorities as a result of your professional activities?:
Yes   No       If "YES", please explain below:
Do you have any financial interest in any projects for which you have provided professional services?:
Yes   No       If "YES", please explain below:
If yes, Is coverage for such Equity Interest desired?:
Yes   No       If "YES", please explain below:

QA / QC Issues
Does current employer have a written Quality Assurance/Quality Control Program?:	Yes  No
Does the principal check all surveys/plans before they are sent to the field/client?:	Yes  No
Does the firm have an in-house program of continuing education for you to utilize?:	Yes  No
Have you participated in an Organizational Peer Review in the past five years?:	Yes  No
Please list all professional societies or associations to which you are a member:

Claims / Liability Issues

Have any Professional Liability claims been made against You in the past 5 years?:

Yes   No       If "YES", please explain below:

Do you have any knowledge of prior acts, errors, omissions or unresolved job controversy or other matter or circumstance which might reasonably be expected to give rise to a claim under this insurance?:

Yes   No       If "YES", please explain below:

Does your current employer have any pending dispute concerning the payment of fees to them for services rendered?:

Yes   No       If "YES", please explain below:

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. 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 the "Claims / Liability Issues" section of this Application, such information shall be revealed immediately in writing to the Underwriter.
Your Name:
Date:
Sign:

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.     then