Fillable Architects And Engineers Renewal Application

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Architects And Engineers Renewal Application

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Page 1 of 6
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
ARCHITECTS & ENGINEERS PROFESSIONAL LIABILITY
RENEWAL APPLICATION
1. Current Kinsale policy number:
2. Legal name of the business who is the primary applicant and will be the first named insured listed on the policy:
3. Please list all other business/dba names for which are you seeking coverage under this policy:
_________________________________________________________________________________________________
4. Please list any names of predecessor firms and dates of each:
____________________
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. Are you looking for coverage for entities listed in question 4 (above) under this policy? Yes No
_________________________________________________________________________________________________
7. Primary location address:
8. 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 past 12 months or are any such changes
contemplated in the next 12 months?
If “Yes”, please provide a description of the changes on an attached sheet of paper.
Please indicate the
number of total staff in
each category Architects Engineers
Land
Surveyors
Landscape
Architects All Other Total
Next 12
Months
Next 12
Months
Next 12
Months
Next 12
Months
Next 12
Months
Next 12
Months
Principals, Partners,
Officers & Directors:
Licensed Staff
Unlicensed Staff
1. Please help us understand the size of your business. Please provide previous year information and future year
projections.:
Projection for
12 months
next Most recent
a.
past 12 months
Projects insured separately $______________ $______________
b. Joint Venture projects* $______________ $______________
c. Projects permanently abandoned $______________ $______________
d. Fees passed through to consultants $______________ $______________
APPLICANT’S INFORMATION
GENERAL INFORMATION
Page 2 of 6
e.
Direct Reimbursables
Projection for
12 months
next
$______________
Most recent
past 12 months
$______________
f.
g.
All other professional services
Annual Total Construction Values
$______________
$______________
$______________
$______________
h. ANNUAL TOTAL REVENUES $______________ $______________
Please categorize your total annual gross revenue by type of work performed:
Next 12 Months Next 12 Months
Architecture _________% Golf Course Architecture _________%
Acoustical Engineering _________% HVAC Engineering _________%
Chemical _________% Interior Design _________%
Civil Engineering _________% Landscape Architecture _________%
Communication Engineering
_________%
_________%
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______________ _________%
2. Please categorize your projects by indicating the percentage in each of the following areas:
Next 12
Months
Next 12
Months
Next 12
Months
Airport Facilities
(except terminals) %
Houses/Single
Family Residential % Roads/Highway/ Streets %
Airport Terminals %
Industrial Waste
Treatment % Schools/Colleges %
Amusement Rides %
Jails/Justice/
Correctional %
Shopping Ctrs/
Retail/Restaurant %
Apartments %
Landfills/Solid
Waste Facilities % Storm Water Systems %
Assisted Living Fac. % Libraries % Tract housing %
Bridges less than 500
feet %
Manufacturing/
Industrial % Tunnels %
Bridges-more than
500 feet % Mass Transit % Warehouses %
Churches/
Religious %
Multi-family Resid. 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) %
Custom Residential %
Office Buildings/ Banks-
Low Rise
<15 stories) % Other (specify) %
Dams
%
Parking Structures
%
Other (specify)
%
Dormitories % Parks/Playgrounds/ Pools %
Environmental
Remediation % Petro/Chemical %
*if any value is present, fill out Joint Venture Supplemental form
Page 3 of 6
Harbors/Piers/
Ports % Potable Water Systems %
Hospitals/
Health Care % Real Estate Development %
Hotels/Motels % Recreation/Sports % Total
100%
3. 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):_____________________________________________________ _________%
4. Has the firm participated in any of the following projects or services in the past 12 months, or are any contemplated for the
next 12 months?
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.
5. During the past 12 months, or during the next 12 months, does or will a single client provide Yes No
over 25% of gross receipts?
If “Yes”, please provide the name of the client, the specific dollar value of this work, and a description of the work
performed:
6.
Provide details of the five (5) largest projects undertaken during the last 12 months.
Name of project Type of structure & services performed Construction value Length of project
7. During the past 12 months, did you:
a) Have unresolved fee disputes? If yes, please describe the date, circumstances and Yes No
amount below.
b) Bring suits, including placement of liens, against clients to collect fees? If yes, please describe Yes No
the date, circumstances and amount below.
c) Do contracts used include arbitration provisions to govern disputes with clients? Yes No
Page 4 of 6
d) Do contracts state that any dispute will be governed by the laws of a certain state? If yes, list the Yes No
state below.
e) Do contracts indemnify another party for any reason when it comes to professional liability? Yes No
Descriptions for a. b. and d:
8. 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 Yes No
authority for stopping work for unsafe practices?
c) Do you oversee/assume the responsibility for the means and method of construction Yes No
on 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 to 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.
9. After inquiry with each person as appropriate, during the last 12 months, 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.
10. After inquiry with each person as appropriate, have any new claims/incidents/circumstances Yes No
been reported to any previous carrier including under an extended reporting period?
If “yes”, please complete a separate Supplemental Claim form for each claim or suit and include
a currently valued loss run for each claim.
11. Please provide details of any status changes in previously reported claims including changes in
amounts paid in defense costs or to settle claims.
Please include an updated loss run for any previously reported unresolved claims.
12. 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.
13. 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 last 12 months?
INSURANCE AND LOSS HISTORY
Page 5 of 6
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.
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.
Page 6 of 6
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: __________________________________________________________________________
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Architects And Engineers Renewal Application

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Completed 2 July 2020

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