PROFESSIONAL LIABILITY INSURANCE APPLICATION:
ARCHITECTS & ENGINGEERS

NOTICE:THE POLICY FOR WHICH APPLICATION IS MADE APPLIES ONLY TO “CLAIMS�? FIRST MADE DURING THE POLICY PERIOD. THE LIMITS OF LIABILITY SHALL BE REDUCED BY “CLAIM EXPENSES�? AND “CLAIM EXPENSES�? SHALL BE APPLIED AGAINST THE DEDUCTIBLE. PLEASE READ THE POLICY CAREFULLY.

If you need more space to answer any questions, please attach a separate sheet.

SECTION 1 - COMPANY INFORMATION

  • During the past five (5) years, has your company's name changed or has any other business been purchased orconsolidated?

    Is your company controlled or owned by any other entity or individual not employed by Applicant?

    Do any officers, principals or officers own interest in any other entity?

    If yes, please provide details below:

    Owner Name

    % Ownership

    Entity Name

    Nature of Activities

    Entity’s Gross Revenues
    % $
    % $
    % $
    % $

    Does the Applicant provide professional services to any of the above entities or vice versa?

    Please complete the following information on your employees:

    Staff

    # of Full-Time

    # of Part-Time
    Principals, Partners, Officers
    Licensed Professional Staff
    Non-Licensed Professional Staff
    Draftsmen and Other Technical Personnel
    Clerical and Accounting Employees
    Total Staff

SECTION 2 – REVENUE HISTORY

Fiscal Year End

Gross Revenues

Subconsultant Fees

Direct Reimbursables

Permanently Abandoned Projects
2 Years Ago $ $ $ $ $
Last Fiscal Year $ $ $ $ $
Projected Current Year $ $ $ $ $
Estimate for Next Year $ $ $ $ $

SECTION 3 –DISCIPLINES

Please indicate the percentage (%) of the following Disciplines - continued on next page

Discipline

% Revenues

Discipline

% Revenues
Acoustical Engineering % Laboratory / Materials Testing %
Architecture % Landscape Architecture %
Civil Engineering % Land Surveying – Construction Stak %
Civil Wastewater Engineering % Land Surveying – Boundary / Topographic %
Construction/Project Management % Land Surveying – Other %
Electrical Engineering % Mechanical Engineering %
Environmental Engineering % Naval/Marine Engineering %
Forensic Engineering % Process / Chemical Engineering %
Geotechnical Engineering % Structural Engineering %
HVAC Engineering % Other (describe) %
Interior Design % Other (describe) %

Please indicate the percentage (%) of revenues derived from the following Services (must equal 100%
Feasibility studies, master plans, reports, surveys $
Design without Construction Observation % $
Design with Construction Observation % $
Construction/Project Management: Agency (not responsible for jobsite safety) % $
Construction/Project Management: At-Risk (responsible for jobsite safety & construction ways) % $
Construction Observation without Design % $
Inspection services on existing structures % $
Manufacture, sale or distribution of any product or process % $
Development, sale or leasing of computer software to others % $
Other (describe) $

SECTION 4 – PROJECT TYPES

Please indicate the percentage (%) of the following Project Types - CONTINUED on next page:

Residential

% Revenues

Industrial

% Revenues

Apartments % Mines / Quarries %
Condominiums % Oil Refineries / Pipelines %
Townhomes % Processing / Manufacturing Facilities %
Single Family – Subdivisions % Utilities / Power Plants %
Single Family – Custom Homes % Other (describe) %

Institutional

% Revenues

Infrastructure

% Revenues

Churches % Airport Runways %
Schools K-12 & Colleges % Bridges / Tunnels / Dams %
Courthouses / Gov’t Buildings % Landfills %
Hospitals % Harbors / Docks / Piers %
Jails % Mass Transit Systems %
Retirement Facilities % Roadways & Highways %
Military Facilities % Utilities %
Libraries / Museums % Water or Wastewater Systems %
Other (describe) % Other (describe) %

Commercial Buildings

% Revenues

Environmental

% Revenues

Airport Terminals % Asbestos / Mold Abatement %
Banks % Compliance Reporting / Consulting %
Hotels / Motels % Phase I & II - Assessments %
Offices % Phase III - Evaluations %

Commercial Buildings

% Revenues

Environmental (continued)

% Revenues

Parking Garages % Remediation %
Restaurants % Permitting %
Retail / Malls / Shopping Centers % Training %
Other (describe) % Other (describe) %

Recreational

% Revenues

Recreational

% Revenues

Amusement Parks / Zoos % Stadiums / Arenas %
Casinos % Convention Centers %
Parks / Playgrounds / Pools % Other (describe) %

What percentage (%) of your projects are provided using the following Project Delivery Methods:

Delivery Method

% Revenues
Design / Bid / Build %
Design / Build – Contractor Led %
Design / Build – Designer Led %
Fast Track %
Engineer / Procure / Construct (EPC) %

What percentage (%) of your projects are attributable to the following Client Types:
Contractors % Local Government %
Design Professionals % State Government %
Real Estate Developers % Federal Government %
Owners % Other (describe) %

SECTION 5 – RISK MANAGEMENT

Please complete the questions below:

Yes

No
Do you or any related entity ever have single-point responsibility for both Design & Construction of a project?
Do you or any related entity engage in actual construction, erection, manufacturing, fabrication or real
Do you design any projects using a model-based technology, such as Building Information Modeling (BIM)?
Do you provide services on projects that are LEED certified?
Do any projects incorporate specifications based on MASTERSPEC?   If yes, what %? %
Do you have a written in-house quality control procedure?
Have you participated in a peer review program in the past year?
Do you have continuing education and training programs for professional personnel?
Do you collect certificates from your sub-consultants?
What % of your sub-consultants are insured for Professional Liability? %
Do you have a client selection process?
What percentage (%) of your work is derived from repeat clients? %
Do you work with other firms injoint ventures?
If yes, please provide details:

What percentage (%) of the Applicants’ services are performed under the following Contract Types:

CONTRACT TYPE

%
Professional Association Contract
Client Drafted Contract
Your Standard Contract
Your Firm’s Letter of Agreement
Purchase Orders
Verbal Agreement
Other (describe)

What % of your written agreements contain a “Limitation of Liability�? provision in your favor?

Other (describe)

Does it Limit your Liability to $250,000 or less?

SECTION 6 – CURRENT INSURANCE

Do you currently have Professional Liability coverage in place?

Carrier Name

Policy Period

Per Claim/Aggregate
Limits

Deductible

Premium
Retroactive Date on your current Professional Liability policy: Date:

What percentage (%) of the Applicants’ services are performed under the following Contract Types:

Yes

No
Do you have “First Dollar Defense�??
Do you have a Project-Specific Limit?
Do you currently have a General Liability policy?
If yes, what is: Carrier: Expiration Date Limits
Have any of the Applicant’s principals, partners, directors or officers ever been subject to disciplinary action by authorities as a result of their professional activities?
If Yes, please provide details:
Has any professional liability claim or suit been brought against the Applicant, its predecessor(s) or any former principal, partner, director, or officer in the past five (5) years?
Do you or any director, partner or officer have knowledge of any incident, act, error or omission that is or could be the basis of a professional liability claim?

SECTION 7 – NOTICES

ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT S(HE) IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD.

NOTICE TO ARKANSAS APPLICANTS:"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."

NOTICE TO OKLAHOMA APPLICANTS:"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."

SECTION 8 – SIGNATURE

I / We declare that if the firm or any of its members become aware of any information that would change answers furnished in the application, the firm will reveal such information in writing to the Company prior to the effective date of coverage.

On behalf of the applicant firm, I declare that this application, including attachments, supplementary pages and other exhibits attached, is complete and correct to the best of my knowledge and belief. I understand that the application shall form the basis of the contract of insurance should the Company offer coverage and should the firm accept the Company’s quotation. I also understand that completion of this application does not bind the Company or broker to provide insurance.

(Owner, Partner, Authorized Officer)