Fill - Free fillable APPLICATION FOR ARCHITECTS AND ENGINEERS PROFESSIONAL LIABILITY INSURANCE (RT Specialty) PDF form

AE-30000-04 07/08 Page 1 of 7

APPLICATION FOR ARCHITECTS AND ENGINEERS PROFESSIONAL LIABILITY INSURANCE

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 space is insufficient to answer any question fully, attach a separate sheet.

I. GENERAL INFORMATION

1. (a) Full name of Applicant (if corporation or LLC provide entity name):

(b) Principal business premises address:

(Street) (County)

(City) (State) (Zip)

(d) Phone Number:

(e) Website address: (f) Date organized (MM/DD/YYYY):

(g) Business is a: [ ] corporation [ ] partnership [ ] sole proprietorship [ ] limited liability company (LLC)

[ ] individual [ ] other

2. Is the Applicant affiliated with any other organization through common ownership? ............................ [ ] Yes [ ] No

If Yes, provide details.

3. During the last five years has the Applicant:

(a) Been involved in, or are they presently considering any merger, consolidation or acquisition? .... [ ] Yes [ ] No

(b) Changed its name?......................................................................................................................... [ ] Yes [ ] No

If Yes to either of the above, provide details.

4. Does the Applicant or any subsidiary, parent organization or affiliated organization engage in actual construction or

subcontract construction or installation on the Applicant’s own projects?............................................... [ ] Yes [ ]No

If Yes, complete our Supplement for Construction Related Services (AE-31000-01).

II. FINANCIAL AND STAFFING INFORMATION

1. Provide the following:

Projected for

Last Year Present Year Upcoming Year

From To From To From To

Total Gross Annual Fees: $ $ $

Total Construction Values: $ $ $

Total Gross Annual Payroll: $ $ $

Total Number of Staff:

Number of Design Professionals:

Submit Application

AE-30000-04 07/08 Page 2 of 7

2. Provide the following for each of the Applicant’s key professionals:

States in Which No. of Years

Name and Title University/Year/Major Licensed/Registered With Applicant

3. What professional associations do the Applicant and/or it’s staff members belong to?

III. PROFESSIONAL DISCIPLINES AND SERVICES

1. Provide the approximate percentage of the professional disciplines in which the Applicant is engaged.

Architecture Engineering (cont’d.) Construction Management* %

Building % Environmental % Design-Build* %

Interiors % Fire Protection % Fabrication %

Landscape % Forensic % Hydrogeology %

Naval % HVAC % Interior Design %

Engineering Mechanical % Land Surveying %

Acoustical % Process % Manufacturing %

Chemical % Soils % Materials Testing %

Civil % Structural % Other %

Electrical % Other % TOTAL 100%

* If the Applicant provides Construction Management and/or uses the Design-Build project delivery method

complete our Supplement for Construction Related Services (AE-31000-01).

2. Does the Applicant subcontract work for any of the above professions? .............................................. [ ] Yes [ ] No

If Yes, answer the following.

(a) What percentage of work for the above professional disciplines is subcontracted to others? %

(b) Which professional disciplines are subcontracted?

all subcontractors? ......................................................................................................................... [ ] Yes [ ] No

3. Provide the approximate percentage of specialty services performed by the Applicant.

Alterations % Foundation Design % Permitting %

Building Design % Geotechnical Services % Product Design %

Construction Staking % Machinery Design % Subdivision Layout %

Cost Estimating % Mapping % Testing %

Expert Witness % Master Planning % Other %

4. Provide the approximate percentage of the scope of services performed by the Applicant.

Design With Construction Observation/Administration % Feasibility Studies/Reports %

Design Without Construction Observation/Administration % Inspection/Certification %

Construction Observation/Administration Without Design % Consulting Not Resulting in Construction %

TOTAL 100%

IV. PROJECTS AND CLIENTS

1. Provide the approximate percentage of work performed during the last three years for each of the following project

sizes based on the project’s total construction value:

< $1,000,000 % > $25,000,000 - $100,000,000 %

$1,000,000 - $25,000,000 % > $100,000,000 %

2. Based on the total construction values, provide the approximate percentage of work during the last three years for

each of the following based on the contractual timeframe for completion of projects:

< 1 year % 1 year to 3 years % > 3 years %

3. (a) Based on total construction values, provide the percentage of work in each of the three largest states:

State % State % State %

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(b) Does the Applicant work on any projects outside of the United States? ........................................ [ ] Yes [ ] No

If Yes, provide the percentage of gross fees and the name, fees, construction value and location of each project.

4. Does the Applicant specialize in specific types of projects? .................................................................. [ ] Yes [ ] No

If Yes, provide details.

5. Provide the approximate percentage of general project types during the last year for each of the following:

Commercial/Retail % Institutional % Recreational %

Industrial/Manufacturing % Public Infrastructure % Residential %

6. Provide the approximate percentage of any of the following project types:

Bridges/Dams: Condominiums: Amusement Rides %

< 100 feet % < 10 units % Bleachers/Grandstands %

100 - 500 feet % 10 - 100 units % Cellular Communication Towers %

> 500 feet % > 100 units % Chemical/Petrochemical %

Buildings: % Custom Homes: % Mines/Tunnels %

< 10 stories % < $1,000,000 % Offshore/Marine Structures %

10 - 50 stories % $1,000,000 - $5,000,000 % Parking Structures %

> 50 stories % > $5,000,000 % Schools %

7. Alternative Energy or Alternative Fuel Projects – Within the past five years, has the Applicant provided any kind

of professional or other service relative to any kind of alternative energy or alternative fuel project, including, but not

limited to, any Biodiesel, Biofuel, Ethanol, Geothermal, Solar Power or Wind Energy project? ............ [ ] Yes [ ] No

(a) If Yes, provide complete description. ___________________________________________________________

_____________________________________________________________________________________________

8. Provide the approximate percentage of clients in each of the following:

Commercial/Industrial % Development Company %

Construction/Contracting Company % Governmental/Public Entity %

Design Professional % Residential %

9. (a) Provide the following information for each of the five largest projects COMPLETED in the last three years:

Date Date

Construction Design Construction

Project Name Location Value Began Completed

(b) Provide the following information for each of the three largest CURRENT projects:

Date Scheduled

Construction Design Completion

Project Name Location Value Began Date

V. BUSINESS PRACTICES AND RISK MANAGEMENT

1. Has/have any suit(s) for collection of fees been filed against any client or any other party during the

last two years? ........................................................................................................................................ [ ] Yes [ ] No

If Yes, complete the following for each suit. If additional space is needed, include attachment.

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Date Suit Filed Total amount of Fees Owed Name of Client/Defendant Name of Project

2. Does any one client represent more than 50% of the Applicant’s business during the last two years? [ ] Yes [ ] No

If Yes, provide details.

3. Has the Applicant ever entered into or do they anticipate entering into any joint venture contracts? .... [ ] Yes [ ] No

Note the basic policy form excludes coverage for joint ventures. If coverage is requested complete our Joint Venture

Supplement (SM1859).

4. Has the Applicant ever provided or does the Applicant expect to provide any professional services

on any project in which the Applicant or any employee of the Applicant had, has, or will have any

ownership interest? ................................................................................................................................. [ ] Yes [ ] No

If Yes, complete our Equity Interest Supplement (SM1861-02).

5. Does the Applicant:

(a) Employ a full time office administrator or business manager? ....................................................... [ ] Yes [ ] No

(b) Use association approved standard contracts for at least 75% of its work? .................................. [ ] Yes [ ] No

(c) Have all contracts for each new project reviewed by legal counsel? ............................................. [ ] Yes [ ] No

(d) Obtain subrogation waivers? .......................................................................................................... [ ] Yes [ ] No

(f) Have at least 75% of its projects in the last three years:

(i) With repeat clients? ............................................................................................................... [ ] Yes [ ] No

(ii) With repeat consultants and contractors? ............................................................................. [ ] Yes [ ] No

(g) Avoid guaranteeing the success of any project? ............................................................................ [ ] Yes [ ] No

(h) Pre-qualify the financial viability of all clients, consultants and subcontractors?............................ [ ] Yes [ ] No

(i) Have written:

(i) Risk management procedures in place? ................................................................................ [ ] Yes [ ] No

(ii) In-house quality control procedures in place? ....................................................................... [ ] Yes [ ] No

(iii) Change order procedures?..................................................................................................... [ ] Yes [ ] No

(iv) Screening/pre-qualification procedures in place for clients, consultants, and contractors?... [ ] Yes [ ] No

VI. INSURANCE AND CLAIMS HISTORY

1. (a) Limits of Liability - Indicate from the following options:

[ ] $250,000/$250,000 [ ] $500,000/$1,000,000 [ ] $1,000,000/$2,000,000 [ ] $3,000,000/$3,000,000

[ ] $500,000/$500,000 [ ] $1,000,000/$1,000,000 [ ] $2,000,000/$2,000,000 [ ] $5,000,000/$5,000,000

(b) Deductible - Indicate from the following options:

[ ] $2,500 [ ] $5,000 [ ] $10,000 [ ] $25,000 [ ] $50,000 [ ] other

THE COMPANY DOES NOT GUARANTEE TO OFFER ANY OF THE ABOVE LIMITS AND/OR DEDUCTIBLES.

2. List current and prior Architects and Engineers Professional Liability Insurance for each of the last five years:

If none, check here [ ]

Inception/

Insurance Limits of Expiration Dates Retroactive/

Company Liability Deductible Premium (MM/DD/YYYY) Prior Acts Date

AE-30000-04 07/08 Page 5 of 7

3. Provide details of the Applicant’s current General Liability Insurance and Umbrella Insurance:

If none, check here [ ]

Inception/

Insurance Limits of Expiration Dates

Company Liability (MM/DD/YYYY)

General Liability Insurance

Umbrella Insurance

4. Has any insurer declined, canceled, or nonrenewed any Architects and Engineers Professional

Liability Insurance or any similar insurance on behalf of any person(s) or entity(ies) proposed for

this insurance? ........................................................................................................................................ [ ] Yes [ ] No

If Yes, provide details.

5. Has the Applicant or any of its employees ever been the subject of disciplinary action by any authority

as a result of their professional activities? .............................................................................................. [ ] Yes [ ] No

If Yes, provide details.

6. Have any of the Applicant’s projects during the last five years:

(a) Been abandoned or stopped before the completion of either design, construction/installation? ... [ ] Yes [ ] No

(b) Been foreclosed, or has any client, contractor or consultant gone into bankruptcy or

receivership?................................................................................................................................... [ ] Yes [ ] No

(c) Been involved in any litigation or arbitration proceedings? ............................................................ [ ] Yes [ ] No

(d) Been subject to any unresolved compensation dispute between the Applicant and any party?.... [ ] Yes [ ] No

(e) Had any party to a contract threaten to make a claim or demand based on actual or alleged

cost overruns, excessive costs, delays, or any failure to meet the contract’s price or time frame?[ ] Yes [ ] No

(f) Had a death or permanent disability occur during construction or installation? ............................. [ ] Yes [ ] No

(g) Have a General Liability Insurance claim reserved for or that was paid for at least $500,000? .... [ ] Yes [ ] No

(h) Resulted in the Applicant filing a claim or suit against any client? ................................................. [ ] Yes [ ] No

(i) Been damaged in any way, or delayed in completion, due to a windstorm, hurricane, flood or

any other kind of weather related event? ..................................................................................... [ ] Yes [ ] No

(j) Been damaged in any way, or delayed in completion, due to an earthquake, earth subsidence,

building or wall collapse, or any other kind of geologic or seismic event?.............................. [ ] Yes [ ] No

If Yes to any of the above, provide details including the current status of the project and contract.

7. Has (have) any Professional Liability claim(s) been made against the Applicant or any person or

entity?...................................................................................................................................................... [ ] Yes [ ] No

If Yes, provide details in Part VII. of the application and attach currently valued loss runs from the

current insurer and any prior insurers.

8. Is (are) any person(s) or entity(ies) proposed for this insurance aware of any fact, circumstance or

situation that might provide grounds for any claim under the proposed insurance? .............................. [ ] Yes [ ] No

If Yes, provide details in Part VII. of the application.

AE-30000-04 07/08 Page 6 of 7

VII. CLAIMS DETAILS

If Yes to Question 6. or 7. in Part VI., provide details below for each claim, fact, circumstance or situation. If more space is

needed, attach additional pages.

1. Date Claim Made: Date of Alleged Error:

Current Status/Date settled: Claim, Suit or Incident:

Name and Location of Project:

Claimant(s)/Plaintiff(s):

Additional Defendant(s) (if any):

Nature of Claim and Allegations:

Date Reported to Insurance Company and Name of Insurance Company:

Amount Reserved (Loss/ Expense): $ /$ Amount Paid (Loss/Expense):$ /$

2. Date Claim Made: Date of Alleged Error:

Current Status/Date settled: Claim, Suit or Incident:

Name and Location of Project:

Claimant(s)/Plaintiff(s):

Additional Defendant(s) (if any):

Nature of Claim and Allegations:

Date Reported to Insurance Company and Name of Insurance Company:

Amount Reserved (Loss/ Expense): $ /$ Amount Paid (Loss/Expense):$ /$

3. Date Claim Made: Date of Alleged Error:

Current Status/Date settled: Claim, Suit or Incident:

Name and Location of Project:

Claimant(s)/Plaintiff(s):

Additional Defendant(s) (if any):

Nature of Claim and Allegations:

Date Reported to Insurance Company and Name of Insurance Company:

Amount Reserved (Loss/ Expense): $ /$ Amount Paid (Loss/Expense):$ /$

AE-30000-04 07/08 Page 7 of 7

NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY

No fact, circumstance or situation indicating the probability of a “Claim” or action for which coverage may be afforded by

the proposed insurance is now known by any person(s) or organization(s) proposed for this insurance other than that

which is disclosed in this application. It is agreed by all concerned that if there is knowledge of any such fact,

circumstance or situation, any “Claim” subsequently emanating therefrom shall be excluded from coverage under the

proposed insurance.

For the purpose of this application, the undersigned authorized agent of the person(s) and organization(s) proposed for

this insurance declares that to the best of his/her knowledge and belief, after reasonable inquiry, the statements in this

application and in any attachments, are true and complete. The underwriting manager, Company and/or affiliates thereof

are authorized to make any inquiry in connection with this application. Signing this application does not bind the Company

to provide or the Applicant to purchase the insurance.

This application, information submitted with this application and all previous applications and material changes thereto of

which the underwriting manager, Company and/or affiliates thereof receives notice is on file with the underwriting

manager, Company and/or affiliates thereof and is considered physically attached to and part of the policy if issued. The

underwriting manager, Company and/or affiliates thereof will have relied upon this application and all such attachments in

issuing the policy.

If the information in this application and any attachment materially changes between the date this application is signed

and the effective date of the policy, the Applicant will promptly notify the underwriting manager, Company and/or affiliates

thereof, who may modify or withdraw any outstanding quotation or agreement to bind coverage.

The undersigned declares that the person(s) and organization(s) proposed for this insurance understand that:

(i) the policy for which this application is made applies only to “Claims” first made during the “Policy Period”;

(ii) unless amended by endorsement, the limits of liability contained in the policy shall be reduced, and may be

completely exhausted by “Claim Expenses” and, in such event, the Company will not be liable for “Claim Expenses”

or the amount of any judgment or settlement to the extent that such costs exceed the limits of liability in the policy;

and

(iii) unless amended by endorsement, “Claim Expenses” shall be applied against the “Deductible”.

WARRANTY

I/We warrant to the Company, that I/We understand and accept the notice stated above and that the information

contained herein is true and that it shall be the basis of the policy and deemed incorporated therein, should the Company

evidence its acceptance of this application by issuance of a policy. I/We authorize the release of claim information from

any prior insurer to the underwriting manager, Company and/or affiliates thereof.

Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its,

owners, partners, directors, officers and employees

Must be signed by the owner, principal, partner, executive officer or equivalent (within 60 days of the proposed effective

date).

Name of Applicant Title

Signature of Applicant Date

Notice to New York Applicants: 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.

Notice to Applicants: 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 subjects

the person to criminal and civil penalties.

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APPLICATION FOR ARCHITECTS AND ENGINEERS PROFESSIONAL LIABILITY INSURANCE (RT Specialty)

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