Fillable Architects And Engineers Professional Liability Application

Fill Online, Printable, Fillable, Blank Architects And Engineers Professional Liability Application Form

Use Fill to complete blank online KINSALE INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Architects And Engineers Professional Liability Application

On average this form takes 82 minutes to complete

The Architects And Engineers Professional Liability Application form is 16 pages long and contains:

  • 3 signatures
  • 113 check-boxes
  • 264 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Kinsale Insurance forms online.

BROWSE KINSALE INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 10
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
ARCHITECTS & ENGINEERS PROFESSIONAL LIABILITY APPLICATION
1. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other business/dba names for which you are seeking coverage under this policy:
_________________________________________________________________________________________________
3. Corporation Individual Partnership Municipality For Profit Joint Venture
Other:
4. Please list any names of predecessor firms and dates of each:_____________________________________________
_________________________________________________________________________________________________
Primary location address:
5. Please list any names of other entities that you own or manage or that you do business under (such entities are not
requesting coverage under this policy):
6. County of primary location: Date business originally established: __________________________
7. Total number of branches? List all addresses for additional branches:
8. What is your web-site address? www.
_______
9. What is your phone number?
__________________________________________________
10. Has the name or ownership of the entity changed or has any other business been purchased, Yes No
merged or consolidated with the entity within the last 5 years?
11. Does any entity own or control your business or does your business own or control any entity? Yes No
12. During the past five years, has your name been changed or has any other business purchased, Yes No
merged or consolidated with you?
For questions 9-11, please fully explain any “yes” response, including the names, dates, and revenue impact involved:
13. Please list any associations of which you are a member:
1. Please indicate the number of total staff in each category:
Please indicate the
number of total staff in
each category Architects Engineers
Land
Surveyors
Landscape
Architects All Other Total
Principals, Partners,
Officers & Directors:
Licensed Staff
Unlicensed Staff
APPLICANT’S INFORMATION
GENERAL INFORMATION
Page 2 of 10
2. Please help us understand the size of your business. Please provide projections if a new business:
Projection for
12 months
next Most recent past 12
months
Previous
a.
12 months
Projects insured separately $______________ $______________ $______________
b. Joint Venture projects* $______________ $______________ $______________
c. Projects permanently abandoned $______________ $______________ $______________
d. Fees passed through to consultants $______________ $______________ $______________
e.
Direct Reimbursables
Projection for
12 months
next
$______________
Most
recent
$______________
past 12
months
Previous
12 months
$______________
f.
g.
All other professional services
Annual Total Construction Values
$______________
$______________
$______________
$______________
$______________
$______________
h. ANNUAL TOTAL REVENUES $______________ $______________ $______________
3. Please categorize your total annual gross revenue by type of work performed:
Architecture _________%
Golf Course Architecture
_________%
Acoustical Engineering _________% HVAC Engineering
_________%
Chemical _________% Interior Design
_________%
Civil Engineering _________%
Landscape Architecture
_________%
Communication Engineering _________%
Land Surveying
_________%
Construction Management
Design/Build
Drafting Services
_________%
_________%
_________%
Mechanical Engineering
Oil/Gas Well Engineering
Product Design
_________%
_________%
_________%
Electrical Engineering _________% Process Engineering
_________%
Environmental Engineering _________% Traffic Engineering
_________%
Fire & Alarm Systems _________% Structural Engineering
_________%
Forensic _________% Other______________
_________%
Geotechnical/Soils _________% Other______________
_________%
4. Please categorize your projects by indicating the percentage in each of the following areas:
Projects
Airport Facilities
(except terminals) % Houses/Single Family Residential % Roads/Highways/Streets %
Airport Terminals % Industrial Waste Treatment % Schools/Colleges %
Amusement Rides % Jails/Justice/Correctional %
Shopping
Centers/Retail/Restaurants %
Apartments % Landfills/Solid Waste Facilities % Storm Water Systems %
Assisted Living
Facilities % Libraries % Tract housing %
Bridges-less than 500
feet % Manufacturing/Industrial % Tunnels %
Bridges-more than
500 feet % Mass Transit % Warehouses %
Churches/Religious % Multi-family Residential excl. Condos % Water/Sewer Pipelines %
Condos/Co-ops % Nuclear/Atomic %
Water/Wastewater
Treatment %
Convention Centers/
Arenas/Stadiums %
Office Buildings/Banks-High Rise
(> 15 stories) %
Utilities (Gas, Electric,
Steam) %
*if any value is present, fill out Joint Venture Supplemental form
Page 3 of 10
Custom Residential %
Office Buildings/Banks-Low Rise
<15 stories) % Other (specify) %
Dams % Parking Structures % Other (specify) %
Dormitories % Parks/Playgrounds/ Pools % %
Environmental
Remediation % Petro/Chemical % %
Harbors/Piers/Ports % Potable Water Systems % %
Hospitals/Health Care % Real Estate Development % %
Hotels/Motels % Recreation/Sports % Total 100%
5. Please categorize the service offered by the entity (must total 100%):
Feasibility studies _________%
Design only, no construction phase services _________%
Design with observation of construction _________%
Design with construction management services _________%
Construction management without design _________%
Complete responsibility for construction, including design _________%
Other (specify):_____________________________________________________ _________%
6. Has the firm participated in any of the following projects or services in the last 10 years?
Projects constructed outside the U.S.A.
Yes No Nuclear or Atomic Yes No
Amusement Rides or Water Slides Yes No Refinery or Chemical Yes No
Asbestos Testing or Abatement Yes No Phase I, II or III Site Assessments Yes No
Hazardous or Toxic Waste Yes No Runways or Taxiways Yes No
Laboratory Testing or Analysis Yes No Stadiums or Arenas Yes No
Landfills Yes No Soils Engineering Yes No
Machinery, Equipment or Product Design Yes No Superfund Yes No
Mines Yes No
If “yes”, please provide details of the project(s), including project named, location, client, billings, constructions values
and completion date on a separate sheet of paper.
7.
Does any single client provide over 25% of gross receipts? Check One: Yes No
If “Yes,” please provide the name of the client, the specific dollar value of this work, and a description of the work
performed:
________________________________________________________________________________________________
______
8. Please categorize your type of clients based on the percentage of your gross revenue for the past 12 months (or for the
next 12 months if a start-up entity):
Commercial Government Institutional Design pros Industrial Private/owners Other-describe
% % % % % % %
9. Provide details of the five (5) largest projects undertaken during the last 12 months. If a start-up, please instead provide
a projection of the type and size of projects contemplated:
Name of project Type of structure & services performed Construction value Length of project
Page 4 of 10
10. Does the applicant or any entity related to the applicant firm or its principals engage in any of the following activities:
1. Construction, erection, fabrication, installation or general contracting Yes No
2. Manufacture, sale, leasing or distribution of any product or process Yes No
3. Manufacture, sale, distribute, or leasing computer software to others Yes No
4. Real estate development Yes No
For any “yes” response, on a separate sheet of paper please provide a complete description of the work
performed including the associated annual gross revenue.
11. What percentage of your annual gross revenue is comprised of operations outside the United States?
%
For any operations outside the United States, please list each country, describe the project and the applicable percentage
of revenue:
12. Do you:
a) Use written contracts for all work? If not, what percentage has a contract?________ Yes No
b) Have contracts for each new project reviewed by legal counsel? Yes No
c) Do contracts used include arbitration provisions to govern disputes with clients? Yes No
d) Do contracts state that any dispute will be governed by the laws of a certain state? Yes No
If yes, list the state below.
e) Do contract indemnify another party for any reason when it comes to professional liability? Yes No
f) Avoid guaranteeing the success of any project? Yes No
g) Have a written risk management procedure in place? Yes No
h) Have an in-house quality control procedure? Yes No
i) Have written change order procedures? Yes No
j) Have unresolved fee disputes? If yes, please describe the date, circumstances and Yes No
amount below.
k) Bring suits, including placement of liens, against clients to collect fees? Yes No
If yes, please describe the date, circumstances and amount below.
Descriptions for d, j and k.
14. Has the firm ever provided or does the firm expect to provide any professional services on any Yes No
project in which the firm or any employee of the firm has, had or will have any ownership interest?
If yes, please fill out the equity interest supplement.
15. Have you ever provided, or in the next 12 months will you provide, services in New York? Yes No
If yes, please complete the following questions:
a) What percentage of your projected gross revenue is from work in New York? ___________%
b) Do you accept responsibility/ supervision for site safety programs or do you have the authority Yes No
for stopping work for unsafe practices?
c) Do you oversee/assume the responsibility for the means and method of construction on Yes No
any project?
d) Do you use AIA B141/ CMa or AIA B141-1997 contracts in NY 100% of the time? Yes No
For any “yes” response for b or c, on a separate sheet of paper please explain in detail. If AIA B141/CMa or AIA B141
1997 contracts are not used, please explain and provide a copy of your contract.
Page 5 of 10
13. Provide your entity’s recent insurance history below.
Insurance Company Limits Per
Claim/Aggregate
Policy Period
(Month/Day/Year)
Annual Premium
Current Year
Previous Year 1
Previous Year 2
Previous Year 3
Previous Year 4
14. If you are currently insured for errors & omissions coverage, what is your policy’s retroactive/prior acts date?
(month/day/year) _____/_____/_______ If there is no retroactive date please check here.
If requesting prior acts coverage you will be asked upon binding coverage to provide a copy of your current insurance
declaration page documenting the expiring retroactive date and limits. Prior acts coverage may not be available if
the date of your current retroactive coverage is different from what we have quoted or if there is any gap between
effective dates.
15. Provide details of Applicant's current General Liability Insurance:
General Liability Insurance Company:_____________________ Limits of Liability__________/_______
Inception/Expiration dates ( month/day/year) _____/_____/_______- _____/_____/_______
16. Requested limits: $100k/$300k $250k/250k $500k/$500k $1M/$1M $2M/$2M (other) _________
Requested deductible: $2,500 $5,000 $10,000 $25,000 Other $__________
17. Are you being canceled or non-renewed by your current professional liability carrier? Yes No
If yes, please explain why: ___________________________________________________________________________
18. After inquiry with each person as appropriate, in the last five (5) years, have any claims Yes No
been made against the person or entity applying for insurance, or any of your past or
present members, partners, officers, directors, employees, or any predecessors in business?
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
19. After inquiry with each person as appropriate, are you, or any of your partners, officers, Yes No
directors, or employees, aware of any circumstances, acts, errors, omissions, or any allegations
or contentions of any incident which may result in a claim?
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
20. After inquiry with each person as appropriate, have you, or any of your partners, officers, directors, Yes No
or employees been the subject of any complaint or subject to any disciplinary action by any state
licensing agency or other regulatory body during the past five (5) years?
If “yes”, please provide an explanation of the circumstances and penalty involved. If available,
please provide a copy of the complaint, your response, and a copy of the regulatory body’s decision.
INSURANCE AND LOSS HISTORY
Page 6 of 10
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals
information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE TO LOUISIANA 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 MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an
application for insurance or statement of a 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.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Page 7 of 10
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: ______________________________________ Title: ____________________________________
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date: ____________________________________
Agent/Broker Name: __________________________________________________________________________
click to sign
signature
click to edit
Page 8 of 10
PROFESSIONAL
LIABILITY SUPPLEMENTAL CLAIM APPLICATION
This form is to be completed when the Applicant has been involved in any claim or is aware of an incident which
may give rise to a claim. COMPLETE ONE FORM FOR EACH CLAIM OR INCIDENT.
If space is insufficient to answer any questions fully, attach a separate sheet.
In lieu of attaching suit papers, please provide a complete narrative description of the allegations involved
1. Full Name of Applicant:
2. Full Name of Individual(s) or entity involved in the claim:
3. Additional defendants
4. Full Name of Claimant:
5. Indicate whether: CLAIM SUIT Incident/Circumstance Only (no claim or suit)
6. Date and location of alleged act, error or omission:
7. Date of claim: Date reported to Insurance Company:
8. What is the status of the claim? Closed/Settled Open/Pending Incident/Circumstance
9. IF CLOSED:
Total paid including deductible(s)? Responses such as “unknown” or “unavailable” are insufficient.
Defense costs Loss/compensatory damages
Paid by you-out of pocket $ $
Insurance Company $ $
Date Resolved: _____/_____/_____ Trial Out of Court
10. IF PENDING:
(a) Claimant’s settlement demand? $ _____
(b) Insurer’s reserve amounts? Loss $ Defense $
Defendant’s settlement offer (if any): $
(c) Amounts already spent defending the claim? By you? $ By the insurer? $
(d) What is your best estimate of the likely settlement amount for this matter? $
(e) What is your best estimate of the date when you expect this claim to be resolved?
Note: Answering “unknown” or “unavailable” to the above questions is an insufficient response.
11. Name(s) of Insurer(s) responding to this claim or incident
Policy Number:
Limits of Liability: Deductible:
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 9 of 10
12. Provide narrative description of suit, claim or incident, including the allegations involved, the potential size of injury
and your response:
13. Explain what action(s) have been taken to prevent reoccurrence of a similar claim:
______
_____
I declare that the information submitted herein is true to the best of my knowledge and becomes a part of my
Professional Liability Application. I understand that an incorrect or incomplete statement could void my protection.
Signature of Applicant/Title/Date (Must be signed by a Principal, Partner or Officer of the Firm)
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH
CAROLINA, NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA,
WISCONSIN, AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals
information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE TO COLORADO APPLICANTS: 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false
information materially related to a claim was provided by the applicant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance 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.
NOTICE TO LOUISIANA 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 MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
NOTICE TO NEW MEXICO 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 civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: 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.
click to sign
signature
click to edit
Page 10 of 10
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company, or other person, files an
application for insurance or statement of a 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.
NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose
of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: ______________________________________ Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Architects And Engineers Professional Liability Application

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document