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Application for Land Surveyors Insurance Program

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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:  
Contact Name:  
Date Established:  
Address:  
City:  
State:     Zip:
County:  
Phone:     Fax:
Branch Office:
(Address(es), Phone, Fax)
 
Email Address:  
Website Address:  
Firm is:  
Federal Employers ID# (FEIN):  

Personnel Information
Specify professional personnel per categories below:
 
Number
Number
Licensed/
Registered
Full-Time
Part-Time
Principals, Partners, 
Officers & Directors: 
Land Surveyors: 
Engineers: 
Other Professionals: 
Total Personnel: 

Gross Receipts
Gross receipts to include reimbursable expenses and fees paid to subconsultants:
Current fiscal year ends: 
 
Current Fiscal
Year To Date
Last Fiscal Year
Two Years Ago
Three Years Ago
Please  Identify  Year: 
Gross  Receipts: 
$
$
$
$
Estimated Total Gross Receipts for next fiscal year: 
$
What percentage of Total Gross Receipts
are derived from repeat clients: 
%

Professional Disciplines
Specify as a percentage of the firm's gross receipts:
Total should equal 100%
Land Surveying
Civil Engineering
Other
Total
%
%
%
%
Please describe the firms surveying services and
the nature of the "other" services specified above:
 

Services
Enter the percentages of the firm's gross receipts attributable to the following for the last fiscal year:
Type of Services
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:
%
Geospatial:
%
Scanning:
%
Other:  
%
Total:
%

Clients
Enter the percentages of the firm'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:
%
Manufacturing/Industrial/Utilities:
%
Design Professionals:
%
Oil/Gas Companies:
%
Other:  
%
Total:
%

Projects
Enter the percentages of the firm'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:
%
Oil & Gas: Pipelines
%
Oil & Gas: Well Staking
%
Oil & Gas: Other
%
Other:  
%
Total:
%
Approximately what percentage of the firm's services are rendered on projects involving Bridges, Tunnels, Dams or Hazardous Waste sites?:
%
What percentage of the firm's projects are outside the U.S. and Canada?:
%

Projects II
Please list your 5 largest revenue projects in the last 5 years:
Proj. #1
Proj. #2
Proj. #3
Proj. #4
Proj. #5

Contracts
Enter the percentages of the firm's contracts based upon those used by the firm:
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:
%
Work order:
%
Client contract:
%
Oral agreement:
%
Other:  
%
Total:
%
What percentage of the firm's contracts contain a Limitation of Liability clause?:
%

Financial and Other Interests
 During the past 12 months, has the firm or any principal...
    ...Become involved in a construction or real estate development company or engaged in any actual construction or hired a construction contractor to perform construction work?:
 Yes   No       If "YES", please explain below:
 
    ...Derived more than 50% of last fiscal year's gross receipts from any one client?:
 Yes   No       If "YES", please explain below:
 
    ...Become involved in the manufacture or fabrication of any component, device or system?:
 Yes   No       If "YES", please explain below:
 
    ...Been the subject of disciplinary action by authorities as a result of their professional activities?:
 Yes   No       If "YES", please explain below:
 
 Does the firm or any principal of the firm have any financial interest in any projects for which it has provided professional services?:
 Yes   No       If "YES", please explain below:
 
 Is coverage for such Equity Interest desired?:
 Yes   No       If "YES", please explain below:
 

Subcontractors / Subconsultants
Please provide, as a % of the Total Gross Receipts reported in GROSS RECEIPTS
section, the fees paid to the firm's subconsultants in the following disciplines:

Total should not equal 100%
Civil
Lab Testing
Soils
Other
%
%
%
%
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 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 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, designations held (such as ALTA, ACSM, etc.),
or associations to which the firm or members of the firm belong:
 

Claims / Liability Issues
 Have any Professional Liability claims been made against the firm or any of its members?:
 Yes   No       If "YES", please explain below:
 
 Does the firm or any of its members 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 the firm have any pending dispute concerning the
payment of fees to the firm for services rendered?:
 Yes   No       If "YES", please explain below:
 
Has the firm or any of its members given notice to any other Professional
Liability underwriter of 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       If "YES", please explain below:
 

Limits and Deductibles
The firm would like a quotation based on the following limits and deductibles:
Limit(s): Deductible(s): Other:
$

Insurance History
Has any insurer cancelled or refused to renew any similar
insurance issued to the firm or any of its members?:
 Yes   No       If "YES", please explain below:
 
Please detail Professional Liability insurance for the past three years.
Show current policy and prior two years.
Company
Exact Dates
Limit
Deductible
Premium
From:
To:
$
$
$
$
$
$
$
$
$
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
How Long Insured or Retroactive Date on Current Policy:  
Please provide current General Liability policy information:
Company
Term
Premium
$

Information To Be Submitted
 The following information may be requested prior to binding:

        a.   Claims history/loss summary for the past five years.

        b.   Resumes of key licensed land surveyors/professionals on staff.

        c.   Copy of current policy declaration page (if any) to confirm retro date.

Mail To:   Anco Insurance
3103 Bee Cave Road, Suite 242
Austin, Texas 78746
 
Or Fax To:   (512) 330-9856

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
  (1)   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.
Please check box if you agree with the above Statement #1
  (2)   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.
Please check box if you agree with the above Statement #2
Electronic Signature
  (3)   I am authorized and agree to use electronic signatures to sign this application. By checking the box below, I agree to transact business using electronic communications, electronic records, and electronic signature rather than paper documents.
Please check box if you agree with the above Statement #3
Your Name:  
Your Title:   
Date:  

Important: Please click on the Print Application button prior to the Submit Form 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  

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