Fillable Aspen American Insurance Company 590 MADISON AVENUE, 7TH (All Risks, Ltd)

Fill Online, Printable, Fillable, Blank Aspen American Insurance Company 590 MADISON AVENUE, 7TH (All Risks, Ltd) Form

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

Aspen American Insurance Company 590 MADISON AVENUE, 7TH (All Risks, Ltd)

On average this form takes 65 minutes to complete

The Aspen American Insurance Company 590 MADISON AVENUE, 7TH (All Risks, Ltd) form is 7 pages long and contains:

  • 1 signature
  • 9 check-boxes
  • 250 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your All Risks, Ltd forms online.

BROWSE ALL RISKS, LTD 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
 
ASPEN
ARCHITECTS AND ENGINEERS PROFESSIONAL LIABILITY
AND POLLUTION LIABILITY INSURANCE
NEW BUSINESS APPLICATION
ASPARAP001 0518 Page 1 of 7
Aspen American Insurance Company
590 MADISON AVENUE, 7TH FLOOR
NEW YORK, NY 10022
(A stock insurance company)
IMPORTANT NOTICE
THIS APPLICATION IS FOR A CLAIMS-MADE AND REPORTED INSURANCE POLICY. CLAIM EXPENSES WILL
REDUCE THE LIMIT OF LIABILITY. THE DEDUCTIBLE APPLIES TO BOTH DAMAGES AND CLAIM EXPENSES.
1.
a.
Name of Applicant/Firm:
_____________________________________________________________________
b.
Principal Business Address:
_________________________________________________________________
_________________________________________________________________
County:
State:
ZIP Code:
____________
Business Phone:
Fax:
Internet address:
_______________________
c.
Please list all branch offices on a separate sheet and include a breakdown of the staff at each location.
2.
a.
Applicant’s practice is: Full-time (more than 30 hours/week) Part-time
b.
Date current firm was established:
____________________________
c.
If the firm is less than two years old, attach a resume for the principal(s).
d.
If part-time, specify other employment:
_____________________________________________________
3. List all pre-existing entities, including name changes, acquisitions and mergers, date of existence and nature of the change.
Attach additional details if necessary. Firms that are accepted for coverage will be listed on the policy.
Name of Predecessor Firm
Dates in Existence
Nature of Change
________________________________________
________________________________________
________________________________________
4. Total Staff (include branch offices): Indicate part-time by ½
Officers, partners, owners
Employees
Licensed architects
Licensed engineers
Technical staff
Administrative staff
GENERAL FIRM INFORMATION AND BACKGROUND
ASPARAP001 0518 Page 2 of 7
5. List professional society memberships:
AIA NSPE ACEC ASLA ASCE ASME
ASID ASGCA Other (please specify): ______________________
6. What percentage of professional employees have participated in continuing education programs within the
last two years? ________________ %
7.
a.
Does the firm currently carry professional liability insurance? …………………….
Yes No
If “yes”, provide details of insurance history below:
Insurance Company
Policy Period
Limit of Liability
Deductible
Premium
b. Retroactive date on current policy:___________________________________
8.
Is the firm covered by any professional liability specific project policy? ……………………
Yes No
If “yes”, provide the name and address of project, name of insurance company and term of policy: _____________
________________________________________________________________________________________________
________________ ________________________________________________________________________________
9. Does the firm carry general liability insurance?……………………………………… Yes No
10. Specify the services provided by the firm: (Note: Total must equal 100%)
Architecture
_________%
Civil Engineering
_________%
Interior Design
_________%
Land Surveying
_________%
Landscape Architecture
_________%
Traffic Engineering
_________%
Golf Course Architecture
_________%
Communication Engineering
_________%
Electrical Engineering
_________%
Environmental Engineering
_________%
Mechanical Engineering
_________%
Structural Engineering
_________%
HVAC Engineering
_________%
Process Engineering
_________%
Other (specify):
_________________________________________________
_________%
11. If the firm’s practice includes fees passed through to consultants for architectural, engineering or surveying services:
a. Specify the types of services provided by consultants: ______________________________________________
b. b. Percentage of consultants that carry professional liability insurance:
___________%
c. Consultant’s fees should be specified in question 12.e.
12.
Specify annual revenues:
Second Past
Fiscal Year
From ______ (mo/yr)
To __________
Last Complete Fiscal
Year
From ______ (mo/yr)
To __________
Projection for Current
Year
From ______ (mo/yr)
To __________
a.
Projects insured separately
$
$
$
b.
Joint Venture projects
$
$
$
c.
Fees from foreign projects
$
$
$
d.
Fees from abandoned projects
$
$
$
e.
Fees passed through to consultants
$
$
$
INSURANCE INFORMATION
FIRM’S PRACTICE
ASPARAP001 0518 Page 3 of 7
f.
Direct Reimbursables
$
$
$
g
All other professional services
$
$
$
h.
ANNUAL TOTAL REVENUES
$
$
$
13. Indicate the services provided by the firm: (Note: must total 100%):
a.
Feasibility studies………………………………………………………………………...
_________
%
b.
Design only, no construction phase services…………………………………………
_________
%
c.
Design with observation of construction……………………………………………….
_________
%
d.
Design with construction management services*…………………………………….
_________
%
e.
Construction management without design*……………………………………………
_________
%
f.
Complete responsibility for construction, including design**………………………..
_________
%
g.
Other (specify):_____________________________________________________
_________
%
*Complete the Construction Management Information Sheet.
**Complete the Design/Build Information Sheet.
14. Indicate the types of projects undertaken (Note: must total 100%):
Airports
___%
Environmental Impact Statements
___%
Religious
___%
Apartments
___%
Highways/Roads
___%
Sewer/Water Lines
___%
Bridges less than 500 feet
___%
Hospitals
___%
Shopping Centers
___%
Bridges greater than 500
feet
___%
Hotels/Motels
___%
Site Development
___%
Condominiums
___%
Industrial
___%
Subdivisions/Tract Housing
___%
Convention Centers
___%
Marine/Naval
___%
Subsidized Housing
___%
Correctional Facilities
___%
Mass Transit Lines
___%
Tunnels
___%
Custom Homes
___%
Municipal Water Systems
___%
Warehouses
___%
Dams
___%
Office Buildings
___%
Wastewater Treatment
___%
Educational
___%
Parking Garages
___%
Other (specify):
___%
15. Indicate the types of clients (Note: must total 100%):
Commercial
______%
Institutional
______%
Contractors
______%
Lending Institutions
______%
Design Professionals
______%
Owners who act as builders
______%
Developers
______%
Other (specify):
Governmental
______%
______%
Industrial
______%
16. What percentage of annual billings come from your largest single client? ___________%
17. What percentage of annual billings come from repeat clients? _________%
18. 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
High Rise Structures – 11 or more stories
Yes No
If “yes”, please provide details of the project(s), including project named, location, client, billings, construction values
and completion date.
19. Does the firm provide stand-alone inspections or inspections for transactional purposes?...................................... Yes No
If yes, provide the percentage of billings derived from these activities _______________%
ASPARAP001 0518 Page 4 of 7
20. Does the firm or any enterprise financially related to the firm or its principals, partners, directors or officers engage in
any of the following:
Construction, erection, fabrication or installation………………………………………………………………………….. Yes No
Manufacture, sale or distribution of any product or process……………………………………………………………... Yes No
Real estate development…………………………………………………………………………………………................. Yes No
If “yes”, provide full details.
21. Has the firm ever provided any professional services on projects for which the firm or a related
person or enterprise has acted as a general contractor by providing or subletting construction?…………………… Yes No
If “yes”, provide full details or complete the Design/Build Information Sheet.
22. a. Does the firm wholly or partly own, manage or control any other enterprise?……………………………………. Yes No
If “yes”, provide full details.
b. Is the firm wholly or partly owned, managed or controlled by any other enterprise?…………………………….. Yes No
If “yes”, provide full details.
23. Does the firm provide professional services for any client in which any member of the firm
or their relatives own a financial interest or serves as an officer, director, trustee or partner?……………............... Yes No
If “yes”, provide the name of the client, project, percentage of equity interest, nature of relationship, gross billings
for the last year and type of services.
24. Has the firm participated in a Joint Venture in the last five years?………………………………………………………… Yes No
If “yes”, please attach a Joint Venture Information Sheet or statement providing full details for each joint venture project.
25. a. Does the firm use written contracts on every project?……………………………………………………………….. Yes No
b. If “no”, please indicate the percentage of projects during the last 12 months that used verbal contracts: _____%
Describe circumstances under which verbal agreements are used: _________________________________
_______________________________________________________________________________________
c. What percentage of professional services are rendered under AIA or EJCDC standard forms of
agreement? _____%
d. When non-standard contracts including “letter agreements” and modified AIA or EJCDC contacts are used,
are they reviewed by the firm’s legal counsel prior to signing?…………………………………………................ Yes No
e What percentage of contracts contain limitation of liability language, limiting the insured’s exposure to an
amount that is less than total insurance proceeds? _________%
26. a. Has the firm adopted a policy against suing for fees?……………………………………………………................ Yes No
b. Please indicate the number of suits filed for the collection of fees during the last two years: ______________
27. Does the firm have procedures in place for the pre-screening of clients?................................................................. Yes No
RELATED ENTITIES
RISK MANAGEMENT PRACTICES
ASPARAP001 0518 Page 5 of 7
28. Does the firm have a written internal Quality Assurance/Quality Control program, updated at regular
intervals?....................................................................................................................................................................Yes No
29. Has the firm participated in an Organizational Peer Review or Loss Prevention training in the past five years?..... Yes No
30. Has the firm adopted the use of BIM or other similar system? …………………………………………………………. Yes No
31. Have any claims involving professional services been made against the firm or any
predecessor firm in the last five years?………………………………………………………………………................... Yes No
If “yes”, complete a Claim/Circumstance Information Sheet or attach full details, including actions taken to prevent
similar claims in the future.
32. Has the firm or any predecessor firm reported a potential claims to a professional liability
insurer in the last five years? ……………………………………………………………………………………................. Yes No
If “yes”, complete a Claim/Circumstance Information Sheet or attach full details.
33. After inquiry, is any member of the firm or a predecessor firm aware of any circumstance
that could possibly result in a professional liability claim being made against them? ………………………………… Yes No
If “yes”, complete a Claim/Circumstance Information Sheet or attach full details.
34. Has any member of the firm ever been the subject of a complaint to authorities or
disciplinary action as a result of the professional activities? …………………………………………………................ Yes No
If “yes”, please attach a statement providing full details.
35. Attach a list of the firm’s five largest completed projects. Include the project name, client, location, services
rendered, billings, construction values and completion date.
36. Attach a list of the firm’s five largest current projects, including the details requested in question 35.
37. Please attach any literature, including government forms, brochures or descriptive information which is sent to
new or prospective clients, which describes the firm’s capabilities and practice.
CLAIMS HISTORY
SUPPLEMENTARY INFORMATION
ASPARAP001 0518 Page 6 of 7
Fraud Notice
FRAUD NOTICE – WHERE APPLICABLE UNDER THE LAW OF YOUR STATE
NOTICE TO APPLICANTS OF ALL STATES EXCEPT COLORADO, DISTRICT OF COLUMBIA, KANSAS,
KENTUCKY, LOUISIANA, MAINE, NEW JERSEY, NEW MEXICO, NEW YORK, OHIO, OKLAHOMA, OREGON,
PENNSYLVANIA, TENNESSEE, VERMONT, VIRGINIA, WASHINGTON: Any person who knowingly, and with the intent
to defraud any insurance company or other person, files an application for insurance or statement of claim containing any
material false information or conceals for the purposes 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 and denial of
insurance benefits.
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
POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE
POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM 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 NOTICE TO KANSAS APPLICANTS: an act committed by any person who, knowingly and with intent to
defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an
insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic,
oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating
of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an
insurance policy for commercial or personal insurance which such person knows to contain materially false information
concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material
thereto.
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 AND WASHINGTON 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 a denial of insurance benefits.
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully 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 MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
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.
ASPARAP001 0518 Page 7 of 7
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 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 is subject to a civil penalty not to exceed $5,000.00 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 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 or makes a claim for the proceeds of an insurance policy containing any false, incomplete or
misleading information is guilty of a felony.
NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud or solicit another to defraud
an insurer: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact,
may be violating state law.
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 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 such person to criminal and civil penalties.
NOTICE TO TENNESSEE AND 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.
NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for
insurance may be guilty of a criminal offense and subject to penalties under state law.
BY SIGNING THIS APPLICATION I HEREBY AUTHORIZE THE INSURANCE COMPANY TO USE THE INFORMATION
CONTAINED IN THIS APPLICATION AND IN THEIR FILES FOR THE PURPOSE OF UNDERWRITING THIS INSURANCE.
THE APPLICATION MUST BE SIGNED BY AN OWNER, PARTNER OR PRINCIPAL.
Signed
Date
Title
(Please print name.)
Licensed Insurance Agent
SIGNING THIS APPLICATION OR INCLUDING PREMIUM WITH ITS SUBMISSION DOES NOT BIND THE APPLICANT
OR THE COMPANY TO COMPLETE THE INSURANCE.
Application must be signed and dated to be considered for quotation. A properly completed, signed and dated, original
application will allow for prompt issuance of coverage should quotation be offered and accepted.
click to sign
signature
click to edit
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

Aspen American Insurance Company 590 MADISON AVENUE, 7TH (All Risks, Ltd)

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 20 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document