Fill - Free fillable DESIGNED PROTECTION APPLICATION FOR ARCHITECTS, ENGINEERS AND GREEN (Risk Placement Services, Inc.) PDF form

MAAE 6000 02 11 Page 1 of 9

DESIGNED PROTECTION

APPLICATION FOR ARCHITECTS, ENGINEERS AND GREEN AND SUSTAINABLE DESIGN

PROFESSIONAL LIABILITY INSURANCE

NOTICE: PLEASE READ THIS DOCUMENT CAREFULLY. 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

UNLESS THE POLICY IS AMENDED BY ENDORSEMENT. 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 busi

ness premises address:

(Street)

(City) (County) (State) (Zip)

(d) Phone Number: (e) Website address:

(f) Applicant is a

: [ ] corporation [ ] sole proprietorship [ ] limited liability company [ ] other:

(g) Date organized (MM/DD/Y

Y):

2. Has/have there been any predecessor entity(ies) prior to the organi

zation of the Applicant? ............... [ ] Yes [ ] No

(a) If Yes, provide name(s) and date(s) organized:

3. Is the Applicant affiliated with any other organization through common ownership?.............................

[ ] Yes [ ] No

(a) If Yes, provide details of ownership structure and details on any services performed on any projects together:

4. 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

5. Does the Ap

plicant or any subsidiary, parent organization or affiliated organization engage in

construction / installation / environmental remediation or subcontract construction / installation /

environmental remediation on the Applicant’s own projects?................................................................. [ ] Yes [ ] No

If Yes, complete the Supplement for Construction Related Services (MAAE 6001).

MAAE 6000 02 11 Page 2 of 9

6. Does the Applicant or any subsidiary, parent organization or affiliated organization engage in

manufacturing, fabrication or assembly or subcontract manufacturing, fabrication or assembly, for

which any design or engineering, and/or professional consulting is performed? ................................... [ ] Yes [ ] No

If Yes, please describe and provide the most recent audited interim and annual financial statements.

II. FINANCIAL AND STAFFING INFORMATION

1. Provide the following: Projected for

Last Year Present Year Upcoming Year

MM/YY MM/YY MM/YY

From

To From To From To

Total Gross Annual Fees: $

$ $

Total Construction Values: $

$ $

Total Gross Annual Payroll: $

$ $

Number of Staff/Design Professionals: /

/ /

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

States in Which

Name and Title

University/Degree/Year Licensed/Registered Years With Applicant

3. How many BIM (Building Information Modeling) in-house user licenses does the Applicant have?

4. How many staff are BIM Certified?

5. How many staff are LEED (Leadership in Energy and Environmental Design) Accredited?

6. What Professional Associations does the Applicant and/or its staff members belong to?

III. PROFESSIONAL DISCIPLINES AND SERVICES

1. Provide the percentages of the Professional Disciplines in which the Applicant is engaged. (TO EQUAL 100%)

Architecture...........................................

% Engineering: Chemical........................................ %

Construction Management Civil................................................

Agency............................................

% Electrical ........................................ %

At-Risk ............................................

% Fire Protection ............................... %

Environmental Consulting or Testing....

% HVAC............................................. %

Interior Design.......................................

% Mechanical .................................... %

Landscape Architecture ........................

% Process.......................................... %

Land Surveying .....................................

% Soils / Geotechnical....................... %

Naval Architecture.................................

% Structural ....................................... %

Other (provide details):

Other (continued):

TOTAL 100%

2. Does the Applicant subcontract any of the above professional services?.............................................. [ ] 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?

Insurance obtained from and maintained for all subcontractors and consultants? ........................ [ ] Yes [ ] No

MAAE 6000 02 11 Page 3 of 9

3. Provide the approximate percentage of Specialty Services performed by the Applicant (NEED NOT EQUAL 100%)

Building Information Modeling.. ____% LEED Certified Projects.. ____% Construction Materials Testing......____%

Construction Staking................ ____% Mapping ..........................____% Soils/Geotech Testing Lab ............____%

Equipment / Machinery Design ____% Master Planning..............____% Testing/Inspection of pipelines,

Expert Witness / Forensic........ ____% Permitting........................____% storage tanks or structural steel ..____%

Foundation/Retaining Wall Design ____% Product Design / Testing ____% Other (describe): ____________

Land Use Planning................... ____% Sustainable Architecture ____% __________________________ ____%

4. Provide the approximate percentage of the Scope of Services performed by the Applicant (TO EQUAL 100%)

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%

5. Provide the approximate percentage of each of the following Project Delivery Methods (TO EQUAL 100%)

Design-Bid-Build (traditional) (Includes design only services)......................................... _____%

Design-Build (with construction / installation performed by the Applicant)...................... _____% *

Design-Build (with construction / installation subcontracted by the Applicant)................ _____% *

Agency Construction Management.................................................................................. _____% **

At-Risk Construction Management .................................................................................. _____% **

Consulting and activities that do not result in Design or Construction............................. _____%

TOTAL 100%

* If the applicant uses the Design-Build project delivery method, complete section I. of the Supplement for

Construction Related Services (MAAE 6001).

** If the applicant performs Construction Management, complete section II. of the Supplement for Construction

Related Services (MAAE 6001).

IV. PROJECTS AND CLIENTS

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

sizes based on the project’s total Construction Value: Less than $1,000,000

$1,000,000 - $25,000,000

% $25,000,000 - $100,000,000 % More than $100,000,000 %

2. Based on the total Construction Values, provide the approximate percentage of work during the last two 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 %

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

If Yes, provide largest projects: name, location, construction value and the Gross Annual Fees

for each project:

Gross Annual Fees

1) $

Gross Annual Fees for all remaining foreign projects (inclusive) .................................................. $

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

If Yes, provide details.

5. Provide the percentages of the following General Project Types during the last year: (TO EQUAL 100%)

Commercial/Retail..........

% Institutional / Gov’t.......... % Recreational... % Energy ........... %

Industrial/Manufacturing.

% Public Infrastructure ....... % Residential ..... % Other.............. %

TOTAL 100%

6. Provide the percentages of the following Specific Project Types during the last year: (NEED NOT EQUAL 100%)

Alternative

Energy: Wind, Solar, etc.. ___% Custom Homes (>$1,000,000 Marine / Offshore Structures....___%

Acoustic or Lighting Design ..........___% and <$5,000,000)………... ___%

Mines / Tunnels / Subsurface ..___%

Amusement Rides......................... ___% Custom Homes (>$5,000,000) ___% Nuclear ................................___%

MAAE 6000 02 11 Page 4 of 9

Biodiesel/ Biofuel/ Ethanol Plants.. ___% Energy Conservation………… ___% Parking Structures...............___%

Bridges (> 250 feet)/Dams............ ___% Environmental Remediation ...___% Pipelines / Storage Tanks....___%

Brownfields / Landfills ................... ___% High-Rises (> 5 stories).......... ___% Schools / Colleges ..............___%

Cellular Communication Towers... ___% Highways / Interstates ............ ___% Sewer

/ Septic / Waste Water .. ___%

Chemical / Petrochemical ............. ___% Hospitals / Medical Centers.... ___% Soils / Geotech Sampling…. ___%

Condominiums ............................. ___% Mass Transit …..………………___% Water Intrusion / Roofs

___%

7. Provide the Total Number and Construction Values during for the following types of Residential Projects for the last

three years: # Projects Construction Values # Projects Construction Values

Apartments..........

Custom Homes .............

Condominiums ....

Subdivisions..................

8. During the last year, what percentage of the Applicant’s Services resulted in projects with: (TO EQUAL 100%)

New Construction........

% Additions / Alterations............. % Studies / Reports....... %

Historic Preservation...

% Inspections / Certifications ..... % TOTAL 100 %

9. Provide the approximate percentage of Clients in each of the following during the last year: (TO EQUAL 100%)

Commercial / Industrial ....................

% Development Company.......... %

Construction/Contracting Company.

% Governmental/Public Entity .... %

Design Professional .........................

% Home Owner / Condo Assn.... %

Utility / Energy Company..................

% Other: % TOTAL100%

10. Has the Applicant received more than 50% of their fees from one client during the last year? ............. [ ] Yes [ ] No

If Yes, provide client’s name:

11. During the last year, has the Applicant received awards (e.g., AIA, ASID, NSPE, ASCE, LEED) for

any projects?........................................................................................................................................... [ ] Yes [ ] No

If Yes, provide details.

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

Project Name Project Type Services Provided Applicant's Fees Est Total Construction Value

Owner/Client Location Date Design Began Date Construction Completed

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

Project Name Location Construction Value Date Design Began Scheduled Completion Date

MAAE 6000 02 11 Page 5 of 9

V. BUSINESS PRACTICES AND RISK MANAGEMENT

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

Note: The Policy Excludes Coverage Arising Out Of Joint Ventures. If coverage is to be requested,

complete the Joint Venture Supplement (MAAE 6005).

2. 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, or in which any related entity

of the Applicant through related ownership had, has or will have any ownership interest?................... [ ] Yes [ ] No

If Yes, complete the Equity Interest Supplement (MAAE 6006).

3. Does the Applicant:

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

(b) Have a program of continuing education for all employees?.......................................................... [ ] Yes [ ] No

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

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

(e) When possible, include limitation of liability clauses in contracts?................................................. [ ] Yes [ ] No

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

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

(i) been with repeat clients?........................................................................................................ [ ] Yes [ ] No

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

(h) Avoid providing warranties or guaranties of the success and/or certification of any project?........ [ ] Yes [ ] No

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

(j) 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

) Scre

ening / pre-qualification procedures in place for clients, consultants, and contractors?. [ ] Yes [ ] No

(v) Green Design and Sustainability quality control procedures?................................................ [ ] Yes [ ] No

(vi) BIM (Building Information Modeling) quality control procedures and guidelines?.................. [ ] Yes [ ] No

VI. INSURANCE AND CLAIMS HISTORY

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

[ ] $300,000/$300,000 [ ] $500,000/$500,000 [ ] $1,000,000/$1,000,000 [ ] $2,000,000/$2,000,000

[ ] $500,000/$1,000,000 [ ] $1,000,000/$2,000,000 [ ] $3,000,000/$3,000,000 [ ] $5,000,000/$5,000,000

(b) Deductible - Indicate from the following options:

[ ] $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

3. List current (in force) Project Insurance policies, if any, with the name and address of the project(s):

Project Name Project Address Insurance Company Limits of Liability Policy Term

NOTE: SEPARATELY INSURED PROJECTS WOULD BE EXCLUDED FROM COVERAGE.

MAAE 6000 02 11 Page 6 of 9

4. 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

5. Has any insurer declined, canceled, or non-renewed any Architects and Engineers Professional

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

this insurance? (Missouri Applicants need not reply.) ............................................................................ [ ] Yes [ ] No

If Yes, provide details.

6. 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.

7. Has/have any suit(s) for collection of fees been filed by the Applicant against any client or any other

party during the last two years?............................................................................................................. [ ] Yes [ ] No

If Yes, how many collection suits has the Applicant filed in the last 2 years? ................................................ ________

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

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

(b) Been foreclosed, or has a 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) Been subject to a regulatory, building code, or certification dispute by any municipality or any

other party?............................................................................................................................................ [ ] Yes [ ] No

(f) Been subject to any dispute over proprietary design plans or other intellectual property issues?..... [ ] Yes [ ] No

(g) 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

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

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

(j) Resulted in the Applicant filing a claim or suit (other than for fees) against any client? ..................... [ ] Yes [ ] No

(k) 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

(l) 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

(m) Been damaged in any way, or delayed in completion, due to non-conforming or deficient

building materials?................................................................................................................................. [ ] Yes [ ] No

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

9. 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.

10. 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.

MAAE 6000 02 11 Page 7 of 9

VII. CLAIMS DETAILS

If Yes to Question 9. or 10. 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):$ /$

MAAE 6000 02 11 Page 8 of 9

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”.

For the purpose of this application, the undersigned authorized agent of the person(s) and entity(ies) 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 Company or its underwriting manager, on behalf of the

Company, is 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.

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

FLORIDA AND IOWA BUSINESS REQUIRED INFORMATION

PRODUCED BY (Insurance Agent or Broker):

Producer Name: Producer License No.:

click to sign

signature

click to edit

MAAE 6000 02 11 Page 9 of 9

Notice to Arkansas and West Virginia 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 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 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 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 Maryland Applicants: Any person who knowingly and willfully presents a false or fraudulent claim for payment

of a loss or benefit or who knowingly and 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 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 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 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, makes any 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, with intent to defraud or knowing that he or she is facilitating a fraud

against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of

insurance fraud.

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 cri

minal and civil penaltie

Notice to Tennessee, Virginia 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 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.

Notice to Applicants of all other 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 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.

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

DESIGNED PROTECTION APPLICATION FOR ARCHITECTS, ENGINEERS AND GREEN (Risk Placement Services, Inc.)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank DESIGNED PROTECTION APPLICATION FOR ARCHITECTS, ENGINEERS AND GREEN (Risk Placement Services, Inc.) Form

Related forms

Fillable DESIGNED PROTECTION APPLICATION FOR ARCHITECTS, ENGINEERS AND GREEN (Risk Placement Services, Inc.)

Fill Online, Printable, Fillable, Blank DESIGNED PROTECTION APPLICATION FOR ARCHITECTS, ENGINEERS AND GREEN (Risk Placement Services, Inc.) Form

Related forms

First 20 documents completely FREE!