Professional Liability Insurance Specialists
| Architects & Engineers | Lawyers | Technology |
| Investment Advisors & Consulting |
800-243-6899 Northern CA - Ext. 50000 Southern CA - Ext. 52022 San Diego CA - Ext. 50200 Atlanta GA - Ext. 32080
COMPLETE YOUR APPLICATION
Gigi Yuen
925-660-3514
Gigi.Yuen@ioausa.com
NOTE: THE INSURANCE FOR WHICH THIS APPLICATION REPRESENTS IS WRITTEN ON A CLAIMS MADE AND REPORTED BASIS; ONLY CLAIMS FIRST MADE AGAINST THE INSURED AND REPORTED TO THE INSURER DURING THE POLICY PERIOD AND EXTENDED REPORTING PERIOD, IF APPLICABLE, ARE COVERED SUBJECT TO POLICY PROVISIONS. THE PURPOSE ANY USE OF THIS APPLICATION IS TO OBTAIN A QUOTATION FOR INSURANCE THAT MAY BE SUBJECT TO ADDITIONAL INFORMATION REQUIRED BY UNDERWRITING.
Target Premium: The target premium will be used by underwriters to quickly determine if a competitive premium is available under their underwriter guidelines. The target premium should be 15% less than the current premium paid by the firm.
Contact Name:
Contact Email:
Full Name of Firm Seeking Coverage:
Doing Business As (If Any):
Street Address:
City:
State:
Zip:
Website:
Telephone:
Date firm was established:
Entity Type: Sole ProprietorshipJoint VenturePartnershipCorporationLLCLLPOther:
If other:
List all entities named to the current policy and their dates of existence:
Entity
To
From
4. Do any other entities, or individuals not employed by your firm, have any ownership interest in your firm?
YESNO
Owner’s Name
Percentage of Ownership
5. Does your firm or any KEY PERSONNEL own any interest in any other entity?
If “Yes,” list the owner, amount of ownership, name of entity, relationship to your firm, nature of activities and the entity's GROSS RECEIPTS during the last complete year.
6. Number of Personnel
PART 2
7. Financial Information: Provide your firm’s GROSS FEES attributable to the following years. GROSS FEES means the exact dollar amount of your firm’s gross revenue including amounts received for the services of CONSULTANTS, but not including interest income, rental income, or sales and service taxes.
Projected Fiscal:
Current Fiscal:
Last Completed Fiscal:
**Provide details of projects covered by a separate project policy.
***Provide details of abandoned projects including the name of owner and project locations.
8. Professional Disciplines: Provide the percentages, based on your firm’s GROSS FEES, attributable to the following disciplines provided by your firm, excluding subconsultants. (Note: This section should total 100%.)
9.Types of Projects: Provide the percentages, based on your firm’s GROSS FEES, attributable to the following project types. (Note: This section should total 100%.)
Storm Water Systems:
11. Client Types:
12. Contracting/Consulting: Provide the percentage of your firm’s GROSS FEES that were paid to subconsultants and subcontractors during the last complete year:
% of GROSS FEES
13. What percentage of those Consultants hire by the firm maintains professional liability insurance:
PART 3
14. Business Practices: Does your firm’s practices include or participate in:
•Limitations of Liability provision in contracts:
•If “Yes,” indicate approximate % of project fees containing provision:
•Continuing education and training programs for professional personnel:
•Peer review sponsored by AIA, NSPE, or other?
•LEED Certification or equivalent?
•If “Yes,” indicate approximate % of professional employees certified:
•Actual construction, installation, fabrication or erection?
•Design-Build or Turnkey Construction:
•Development, sale or leasing of computer software or hardware to others:
•Real estate developers:
•Provide services on a project with any principal, partner, officer, director or shareholder of your firm or an immediate family member of any such person owning more than 15% combined ownership interest or act as the managing partner in any entity or project for which professionals services have been or will be rendered?
15. Prior Insurance: Provide the following about your firm’s insurance:
Policy Period:
Per Claim and Aggregate
/
Per Claim and Aggregate Limit
Please provide Alternative Per Claim and Aggregate Limit Quotation.
Per Claim Limit
PART 4
16. Claims Awareness:
a)After inquiry, do any directors, officers, principals, partners, insurance managers, of the firm for which coverage is sought, have knowledge of any incident, a circumstance, an event, or unresolved fee dispute that may result in a claim?
If “Yes,” please provide the claim details on a separate sheet.
b)Within the past 5 years, have any claims been made or legal action brought against the firm, it’s predecessor(s), or any past or present principals, partners, insurance managers, or employees?
THIS APPLICATION WILL BE USED TO OBTAIN AN INDICATION OF PROFESSIONAL LIABILITY INSURANCE. THE UNDERWRITER SELECTED WILL HAVE BINDING SUBJECTIVITIERS THAT WILL INCLUDE THE COMPLETION OF THEIR APPLCIATION.