Professional Liability Application

COMPLETE YOUR APPLICATION

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.

 
PART 1

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

  If “Yes,” list the owners and indicate their percentage of interest in your firm.

Owner’s Name

Percentage of Ownership

 

5.  Does your firm or any KEY PERSONNEL own any interest in any other entity?

 YESNO

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

Principals (Do not include below.)

Professionals (project managers, architects, engineers, scientists)

Technical (CAD operators, field, laboratory)

Administrative and other

Total

 

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:

Design and Consulting Fee:

Fees Paid to Consultants:

Gross Fees:

Reimbursable Expenses:

**Separate Policy Coverage:

***Abandoned Projects:

 

**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%.)

Acoustical Engineer:

Structural Engineer:

Electrical Engineer:

Civil Engineer – Other:

Mechanical Engineer:

Illumination Engineer:

Architect:

Survey:

Environmental Abatement:

Civil Engineer – WWTP:

Process Engineer:

Interior Design:

Architect Planner:

Traffic Engineer:

Geotechnical Engineer:

CM – Advisor:

Laboratory Testing:

CM - At Risk:

Landscape Architect:

*Define Other:
*Other:

**Define Other:
**Other:

 
Acoustical Engineer:

Structural Engineer:

Laboratory Testing:

Electrical Engineer:

Civil Engineer – Other:

CM - At Risk:

Mechanical Engineer:

Illumination Engineer:

Landscape Architect:

Architect:

Survey:

*Define Other:
Environmental Abatement:

Civil Engineer – WWTP:

*Other:

Process Engineer:

Interior Design:

**Define Other:
Architect Planner:

Traffic Engineer:

**Other:

Geotechnical Engineer:

CM – Advisor:

 

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%.)

Airport Facilities:

Shopping / Retail:

Parking Structures:

Hotels / Motels:

Bridges:

Water / Wastewater Pipelines:

Recreation / Sports:

Libraries:

Dormitories:

Airport Terminals:

Stadiums / Arenas:

Parks / Playgrounds / Pools:

Houses (Custom):

Churches / Religious:

Water / Wastewater Treatment:

Residential Subdivision:

Manufacturing / Industrial:

Harbors / Piers / Ports:

Amusement Rides:

Storm Water Systems:

Petro / Chemical:

Industrial Waste Treatment:

Condominium:

Utilities: (Gas, Electric, Steam)

Roads / Highways:

Mass Transit:

Hospitals / Health Care:

Apartments:

Tunnels:

Potable Water Systems:

Jails / Justice:

Convention Centers:

*Other:
Schools / Colleges:

Office Buildings / Banks:

Assisted Living Homes:

Warehouses:

Landfills / Solid Waste Facilities:

Dams:

Airport Facilities:

Shopping / Retail:

Hotels / Motels:

Bridges:

Recreation / Sports:

Libraries:

Airport Terminals:

Stadiums / Arenas:

Houses (Custom):

Churches / Religious:

Residential Subdivision:

Manufacturing / Industrial:

Amusement Rides:

Storm Water Systems:

Industrial Waste Treatment:

Condominium:

Roads / Highways:

Mass Transit:

Apartments:

Tunnels:

Jails / Justice:

Convention Centers:

Schools / Colleges:

Office Buildings / Banks:

Assisted Living Homes:

Warehouses:

Landfills / Solid Waste Facilities:

Dams:

Parking Structures:

Water / Wastewater Pipelines:

Dormitories:

Parks / Playgrounds / Pools:

Water / Wastewater Treatment:

Harbors / Piers / Ports:

Petro / Chemical:

Utilities: (Gas, Electric, Steam)

Hospitals / Health Care:

Potable Water Systems:

*Other:

10. Design and Other Related Services: Did your firm’s services include any of the following during the last fiscal year? If so, please enter in the percentage of GROSS FEES attributable to each.
Building Envelope Review

Inspection Only Services

Design Without Construction Review

Forensic and/or Expert Witness Services

Design / Build

Cost Estimating Without Design

Building Information Modeling (BIM)

Machinery Design

Feasibility, Planning or Studies

Industrial Process Design

Design With Construction Review

Roof Inspection Only Services

Construction Review Without Design

Plan Check Without Design

Building Envelope Review

Inspection Only Services

Forensic and/or Expert Witness Services

Design / Build

Building Information Modeling (BIM)

Machinery Design

Industrial Process Design

Design With Construction Review

Construction Review Without Design

Plan Check Without Design

Design Without Construction Review

Cost Estimating Without Design

Feasibility, Planning or Studies

Roof Inspection Only Services

 

11.  Client Types:

Federal Government:

Design / Build Contractors:

General Contractors:

Real Estate Developers:

Foreign Government:

*Define Other:

Other Design Professionals:

Private Owners:

*Other Percentage:

State Government:

Local Government:

Federal Government:

Design / Build Contractors:

Real Estate Developers:

Foreign Government:

Other Design Professionals:

Private Owners:

State Government:

Local Government:

General Contractors:

*Define Other:

*Other:

 

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

Contractors (if any)

Structural

Consultants (if any)

Other

Environmental

 

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:

 YESNO

 

•If “Yes,” indicate approximate % of project fees containing provision:

 

 

•Continuing education and training programs for professional personnel:

 YESNO

 

•Peer review sponsored by AIA, NSPE, or other?

YESNO

 

•LEED Certification or equivalent?

 YESNO

•If “Yes,” indicate approximate % of professional employees certified:

 

•Actual construction, installation, fabrication or erection?

   YESNO

 

•Design-Build or Turnkey Construction:

 YESNO

 

•Development, sale or leasing of computer software or hardware to others:

 YESNO

 

•Real estate developers:

YESNO

 

•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?

YESNO

   

15.  Prior Insurance: Provide the following about your firm’s insurance:

Insurance Company

Policy Period:

To

Per Claim and Aggregate

/

Per Claim and Aggregate Limit

Please provide Alternative Per Claim and Aggregate Limit Quotation.

 
Please provide Alternative Per Claim and Aggregate Limit Quotation.

Per Claim Limit

Per Claim Deductible

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?

YESNO

 
 

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?

YESNO

If “Yes,” please provide the claim details on a separate sheet.

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.