Answer all questions

This application is for professional liability insurance that is provided on a claims made basis. The policy applies to claims arising out of your professional services performed on or after any retroactive date shown in the policy, and is subject to all policy terms, conditions, declarations and endorsements.

The policy contains a provision permitting claim expenses, including legal defense costs, to be applied the deductible. Subject to restrictions in certain states, the payment of claim expenses reduces the Limits of Insurance available to pay claims and the Company has the right to designate legal counsel and uses panel counsel, as needed, for claims covered by any insurance provided.

Firm's name:
Street address:
Mailing address:
City:
State:
Zip:
Telephone:
Facsimile:
E-mail:
Web Site:
New applicants must submit the following items with this application :
1. Resumés of principals, partners, and officers (KEY PERSONNEL).
2. A list of your firm's 10 largest projects (completed or in progress) within the last five years. This information may be provided by completing the List of Largest Projects or by attaching a copy of your firm's current Standard Form 254.
3. A copy of your firm's standard contract form. If you use unmodified standard professional association forms, provide form numbers only, not copies.
4. Brochures describing your firm's services.
 
FIRM PROFILE
*1. Date firm was established: / / Type:
Other:
*2. List all pre-existing entities, including acquisitions and mergers, and their dates of existence :

Dates (From)
Dates (To)
Firm Name

3. Number of personnel :

Principals (Do not include below)
Professionals (project managers, architects, engineers,scientists)
Technical (CAD operators, drafting, field, laboratory)
Non-Technical (equipment operators and other field personnel)
Administrative and other
Total

*4. List all professional societies and associations to which your firm and KEY PERSONNEL belong :


5. Do any other entities, or individuals not employed by your firm, have any ownership interest in your firm?
If yes, list the owners and indicate their percentage of interest in your firm. .


6. 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.


7. Are professional services provided by your firm to any entity in which your firm or KEY PERSONNEL maintain a cumulative ownership interest greater than ten percent (10%)?
If yes, complete the Entity Ownership Questionnaire.

8. Provide your firm's GROSS RECEIPTS attributable to the following years.
(Include all receipts for projects insured by project policies within the GROSS RECEIPTS column and list separately in the Project Policy Receipts column.) GROSS RECEIPTS means the EXACT dollar amount of your firm's gross revenues, but not including interest income, rental income on real estate, or sales and service taxes.
Month / Day / Year
.
GROSS RECEIPTS
PROJECT POLICY RECEIPTS*
/ /
Estimated Current Year
/ /
Last Complete Year
/ /
Two Years Ago
/ /
Three Years Ago
*Complete Project Insurance Questionnaire
To be considered for a multi-year policy premium quotation, provide your firm's projected GROSS RECEIPTS for next year:

9. List all office locations with a contact name and the percentage of your firm's GROSS RECEIPTS derived from each location for the last complete year:
Location (address, city, state, zip & contact).
%
%
%
%
Total must be 100%
%
10. Provide the percentages of your firm's GROSS RECEIPTS that were paid to subconsultants and subcontractors during the last complete year. %
Subconsultants
Insured for Professional Liability
Not Insured for Professional Liability
Structural Engineering
%
%
Other Professional Services
%
%
11. What percentage of firm's gross receipts during the last complete fiscal year were attributable to:
%
a. Feasibility, programming, planning or economic studies.
%
b. Commercial/industrial projects
%
c. Roads/Highways
%
d. Utilities

DISCIPLINES

12. Provide the percentages, based on your firm's GROSS RECEIPTS, attributable to the following disciplines provided by your firm, excluding your subconsultants.
Estimated current year
Last complete year
ARCHITECTURE
%
%
Architecture
%
%
Architectural planning (including master planning)
%
%
Interior design and graphics
%
%
Landscape architecture
ENGINEERING
%
%
Structural engineering
%
%
Civil engineering
%
%
Civil wastewater engineering (municipal, non-industrial)
%
%
Land surveying
%
%
Traffic engineering
%
%
Mechanical engineering
%
%
Acoustical engineering
%
%
Process engineering
%
%
Electrical engineering
%
%
Illumination engineering
%
%
Totals must equal 100%

CLIENTS

13. Provide the percentage of your firm's GROSS RECEIPTS attributed to the following types of clients during the last complete year.
.Private Sector:
%
Owners
%
Developers
%
Contractors
%
Design Professionals
%
Environmental consultants
%
Other (describe)
%
Public Sector
%
Foreign
%
Total
(must equal 100%)
CLAIMS
14. In the last three years, has your firm had a claim against your practice, or against you on a product policy, as described below?
If yes, complete a Claim Questionnaire for each claim.
(Renewal clients need only complete a Claim Questionnaire for any claim not reported to us during their policy period.)

Claim means : (a) a demand against you for money or services, or the filing of a suit or the initiation of an arbitration proceeding naming you, seeking damages for all alleged error, omission, negligent act : or (b) an event, a circumstance, an incident, or unresolved fee dispute, of which you have knowledge that may result in a claim as described in (a).
INSURANCE

15. Identify your firm's current commercial general liability insurance company :
Expiration date : Policy limits :

*16. Provide the following information about your firm's professional liability insurance :

.
Policy Period
(from/to)
Insurance
Company
Limits of
Insurance
Deductible
Premium
Current Year / $ $ $
Last Year / $ $ $
Two years ago / $ $ $
Three years ago / $ $ $
Four years ago / $ $ $
Retroactive date on current policy :
QUOTATION OPTIONS

17. Indicate which options your firm wishes quoted for professional liability insurance :
Combined Single/
Aggregate Limit		Split Limits Per Claim/
Aggregate		Deductible Per Claim








ADDITIONAL INFORMATION
18. Provide any information that will further our understanding of your firm.



FRAUD WARNING

Arkansas - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado - It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Florida - Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Kentucky - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

New York - Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Ohio - Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma - Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of any insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania - Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claims containing any materially false information or conceals, for the purpose of misleading, information concerning any fact materialthereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

CLAIMS REPRESENTATION / SIGNATURE

I specifically asked all principals and project managers in our firm if they have knowledge of any claim or potential claim against us that is not listed in our response to question 14. There are none.

If we become aware of any claim or potential claim against us, before the inception of coverage, we will immediately inform the Company, Agent or Broker. We understand that any claim or potential claim against us, before the inception of coverage, whether identified to the Company or not, will not be covered by this insurance unless specially accepted by the Company.

On behalf of our firm, I agree that this application, including all attachments and exhibits, is complete and correct to the best of my knowledge and belief. I understand that this application forms the basis of the contract of insurance, if the Company offers coverage and we accept the Company's offer. I also understand that completion of this application does not bind the Company, Agent or Broker to provide insurance.
Name of Principal,Partner, or Officer:
Title:
Date of application:
07/31/2010
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