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Access E&S Insurance Services Inc.
www.access-es.com
ARCHITECTS AND ENGINEERS PROFESSIONAL LIABILITY INSURANCE
THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY
This
Application
for Architects and Engineers Professional Liability Insurance is intended to be used for the preliminary evaluation of a
submission. When
completed
in its entirety, this
Application
will
enable
the
Underwriter
to
decide whether
or not to
authorize
the
binding
of insurance.
THIS APPLICATION IS NOT A BINDER
1. Name of Firm:
Date Established:
2. Address:
County:
3. Branch Office Address(es):
4. Phone: ( )
Fax: (
)
E-Mail:
Website:
5. Firm is:
□
Corporation
□
Partnership
□
Sole Proprietorship
□
Joint Venture
□
Other
PERSONNEL
6. Specify personnel per categories below:
Number
Number
Re
g
istered/Licensed
Full-Time
Part-Time
A. Principals, Partners,
Officers & Directors
B. Architects:
C. Engineers:
D. Land Surveyors:
E. Technical Personnel:
F. Others: (administrative/clerical)
G.
T
otal
P
ersonnel:
GROSS
RECEIPTS
7. Gross receipts to include reimbursable expenses and fees paid to subconsultants. Current fiscal year ends
Gross receipts attributable to:
Current Fiscal Year
Endin
g
/
20
Last Fiscal Year
Endin
g
/
20
Two Years Ago
Endin
g
/20
Three Years Ago
Endin
g
/
20
a. Separately insured projects
$
$
$ $
b. Permanently abandoned projects
$
$ $ $
c. All other fees/billings
$
$ $ $
d. Total Gross Receipts (7a+7b+7c)
$
$
$
$
e. Estimated Total Gross Receipts for next fiscal year $
PROFESSIONAL
DISCIPLINES
8. Specify as a percentage of the firm’s gross receipts. Total should equal 100%.
Architecture % Landscape Architecture % HVAC Engineering %
Civil Engineering % Land Surveying % Fire Protection Engineering %
Mechanical Engineering %
Construction/Project
Management % Construction Materials Testing %
Electrical Engineering % Process Engineering % Mining Engineering %
Structural Engineering % Chemical Engineering % Interior Design %
Soils Engineering % Environmental % Land Use Planning %
Laboratory Testing %
Hydrogeology/Geology % Other %
AE 002 02/04
– 1 –
SER
VICES
PROJECTS
Percent Gross Receipts (must total 100%)
9. a. Design/Studies:
1. Design with construction observation/review
2. Design without construction observation/review
3. Studies, planning, permitting
b. Construction Related Services:
1. Construction Management Services (Agency)
2. Construction Management Services (At risk)
3. Project Management
4. Construction observation/review without design
c. Surveying:
1. Construction Staking
2. Topographic/Boundary Surveys
3. Other
d. Inspections as Stand-Alone Service:
1. Construction Inspection
2. Real Estate Pre-Acquisition
3. Mold Inspection/Investigation
4. Water Intrusion Inspection
e. Miscellaneous Services:
1. Forensic/Expert Witness
2. Plan Checking
3. Quantity/cost estimating
4. Drafting (stand alone service without design)
5. Other :
As a Percent of Gross Receipts (must total 100%)
12. a. Schools, colleges
b. Hospitals, retirement or
convalescent homes
c. Hotels, motels or resort properties
d. Condominiums/Townhouses
e. Residential subdivisions/Tract Homes
f. Custom single family residential
g. Remodel only - single home
h. Apartments
i. Office/Commercial/Retail
j. Government/Public Buildings
k. Industrial/Process
l. Machine design
m. Sports Stadiums/Amusement Parks
n. Public Utilities/Power Generation
o. Jails/Justice
p. Airports
q. Roads/Highways/Traffic
r. Sewage or waste disposal systems
s. Water systems
t. Wastewater Treatment Plants
u. Pipelines
v. Dams/reservoirs/mines/quarries
w. Harbors, jetties, docks or piers
x. Bridges, trestles or tunnels
y. Parking
garages/Theaters/Convention
Ctr.
z.
Falsework/Shoring/Temporary
Structures
Other
13. In the past 5 years has your firm, a predecessor firm or
any other insured provided any services on residential
condominium or townhouse projects?
□
Ye s
□
No
If yes, please provide details and complete the following:
Total number of Condominium/
Townhouse projects?
Approximate total construction value? $
14a. What percentage of the firm’s projects are done on a
Fast Track basis?
%
14b. What percentage of the firm’s projects are outside the
U.S. and Canada?
%
Which countries? (list)
CLIENTS
Percent of Clients (must total 100%)
10. a. Government or Public Entities
b. Owners acting as their own builders
c. Design/Build or turnkey contractors
d. Other contractors
e. Developers
f. Financial and lending institutions
g. Other design professionals
h. Insurance Companies/Attorneys
i. Other
11. What percentage of Total Gross Receipts
in 7d. are derived from repeat clients?
AE 002 02/04
– 2 –
CONTRACTS
15. Please specify types of contracts used by the firm. Must total 100%.
a. Standard industry contract
(AIA, EJCDC, ASFE, etc.)
% e. Client contract %
b. Firm’s own standard contract % f. Oral agreement %
c. Letter agreement
% g. Other %
d. Purchase order % %
16. What percentage of the firm’s contracts contain a Limitation of Liability clause? %
FINANCIAL
AND
OTHER INTERESTS
17. Does the firm have any predecessor firms or related entities?
□
Ye s
□
No
If yes, list all pre-existing entities, including mergers and their dates of existence (below and in the grid provided on question 36).
For all “yes” responses to question 18, please provide details by attachment.
18. During the past 12 months has the firm or any principal:
a. Engaged in actual construction or hired a construction contractor to perform construction work?
□
Ye s
□
No
b. Become involved with or have ownership interest in a construction or real estate development company?
□
Ye s
□
No
c. Been employed by or an officer of any other firm, organization or political body?
□
Ye s
□
No
d. Derived more than 50% of last fiscal year’s gross receipts from any one client?
□
Ye s
□
No
e. Designed a building, component or system which might be used on more than one project?
□
Ye s
□
No
f. Become involved in the manufacture or fabrication of any component, device or system?
□
Ye s
□
No
g. Provided electronic data processing services for others or sold software components?
□
Ye s
□
No
h. Been the subject of disciplinary action by authorities as a result of
professional or business activities?
□
Ye s
□
No
19. a. Has the firm entered into any Joint Ventures?
□
Ye s
□
No
b. Does the firm’s Joint Venture agreement provide for allocation of liabilities?
□
Ye s
□
No
c. Does the firm require evidence of professional liability insurance from all
Joint Venture members?
□
Ye s
□
No
20. a. Does your firm or any principal, partner, officer, director or shareholder of your firm or an
immediate family member of any such person have an ownership interest in any entity
□
Ye s
□
No
or project for which professional services have been or are to be rendered?
b. Other than for third party claims, does your firm seek coverage for these projects?
□
Ye s
□
No
If yes, an Equity Interest Supplemental Application must be submitted.
21. Does the firm have any Abandoned Projects to be excluded from coverage?
□
Ye s
□
No
If yes, an Abandoned Projects Questionnaire must be submitted.
AE 002 02/04
– 3 –
SUBCONTRACTORS
/
SUBCONSU
L
T
ANTS
22. a. Please provide, as a percentage of the Total Gross Receipts reported in Question 7d., the fees paid to the firm’s
subconsultants in the following disciplines (Should not total 100%)
Architecture
% Soils %
Civil
% Structural %
Mechanical
% HVAC %
Electrical
% Other %
b. Describe the firm’s subcontractor and subconsultant selection process:
c. Do you hire subcontractors to perform construction?
□
Ye s
□
No
If yes, please explain:
d. Are all subcontractors and subconsultants hired under a written contract?
□
Ye s
□
No
e. Does the firm obtain certificates of insurance from all subcontractors and subconsultants?
□
Ye s
□
No
QA / QC
ISSUES
23. Does the firm have an Ownership of Documents clause in each contract of hire?
□
Ye s
□
No
If no, what does the firm do to protect itself against reuse of its plans and specifications without knowledge or
authorization?
24. Does the firm have a written Quality Assurance/Quality Control Program?
□
Ye s
□
No
25. Does a principal check all plans before they are sent to the field?
□
Ye s
□
No
26. Does the firm have an in-house program of continuing education
for professional employees?
□
Ye s
□
No
27. Has the firm participated in an Organizational Peer Review in the past five years?
□
Ye s
□
No
28. Please list all professional societies or associations to which the firm or members
of the firm belong:
AE 002 02/04
– 4 –
LIABILITY ISSUES
29. a. Has the firm made adjustments or goodwill payments in any disputes involving its services?
□
Ye s
□
No
If yes, please explain in detail.
b. Have any Professional Liability claims been made against the firm or any of its members?
□
Ye s
□
No
If yes, please use the Claim/Incident Information Supplement provided with this Application.
c. Does the firm or any of its members have any knowledge of prior acts, errors or omissions which might
reasonably be expected to give rise to a claim under this insurance?
□
Ye s
□
No
If yes, please explain in detail.
d. Does the firm or any of its members have knowledge of any deficiencies, property damage or bodily injury,
whether actual or alleged, in connection with projects for which the firm has performed professional services?
If yes, please explain in detail.
□
Ye s
□
No
e. Does the firm have any pending dispute concerning the payment of fees to the firm for services rendered?
If yes, please explain in detail.
□
Ye s
□
No
f. Does the firm or any of its members have any knowledge of any circumstance, incident, situation, accident
condition or unresolved job controversy or other matter which might give rise to a claim under this insurance?
If yes, please explain in detail.
□
Ye s
□
No
g. Has the firm or any of its members testified, provided expert testimony or given a deposition or
statement in any disputes or proceedings where claim has been made or suit filed against any
party to the work or project where the firm provided professional services?
□
Ye s
□
No
If yes, please explain in detail.
h. Has the firm or any of its members given notice to any other Professional Liability underwriter of any actual or
alleged act, error, omission, deficiency, property damage or bodily injury, circumstance, incident, situation,
accident, unresolved job controversy or fee dispute which could result in a claim?
□
Ye s
□
No
If yes, please use the Claim/Incident Information Supplement provided with this Application.
AE 002 02/04
– 5 –
INSURANCE HISTOR
Y
30. Has any insurer cancelled or refused to renew any similar insurance issued to the firm or any of its members?
If yes, please explain in detail.
□
Ye s
□
No
31. Are you currently insured under a Professional Liability Policy?
□
Ye s
□
No
If yes, please detail Professional Liability insurance for the past five years. Show current policy and prior four years.
COMPANY TERM LIMIT DEDUCTIBLE PREMIUM
Retroactive date on current policy:
32. Please provide current General Liability policy information:
COMPANY TERM LIMIT DEDUCTIBLE PREMIUM
33. Is your firm currently insured under a separate, Project Specific professional liability policy?
□
Ye s
□
No
If yes, provide a copy of the Declarations and answer the following:
Project Name
Fees
Insurer Limit/Deductible Policy Term
Ext. Reporting Period
(months)
REQUIRED ADDITIONAL INFORMATION
(must
be
submitted)
34. Please submit the following information along with this application:
a. Current Claims history/Insurance Company loss summary for the past five years.
b. Résumés of key licensed design professionals on staff.
c. List of ten largest projects over the past three years or current Form 254.
d. Firm’s Brochure
35. The firm would like a quotation based on the following limit(s) and deductible(s):
Limit Deductible
NOTE: For deductibles of $50,000 or more, please enclose a copy of the firm’s balance sheet and income
statement for the most recent fiscal year.
AE 002 02/04
– 6 –
ADDITIONAL
FIRM
INFORM
ATION
36. List all predecessor Firms:
37. Please provide any additional information regarding the firm and its services that you wish us to consider:
The applicant has read the foregoing and understands that completion of this Application does not bind the Underwriter
or the Broker to provide coverage. It is agreed, however, that this Application is complete and correct to the best of
applicant’s knowledge and belief and that all particulars which may have a bearing upon acceptability as a Professional
Liability insurance risk have been revealed. It is understood that this Application shall form the basis of the
contract should the Underwriter approve coverage and should the applicant be satisfied with the Underwriter’s quotation.
It is further agreed that, if in the time between submission of this Application and the requested date for coverage to be
effective, the applicant becomes aware of any information which would change the answers furnished in response to
Question 29, or any other question of this Application, such information shall be revealed immediately in writing to the
Underwriter.
Must be signed by Owner, Partner, or Officer.
Print or Type Your Name Title
Signature of Applicant Date
AE 002 02/04
– 7 –
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Completed 8 January 2021

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