Fillable Miscellaneous Professional Liability APPLICATION Architects & Engineers (Risk Placement Services, Inc.)

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Miscellaneous Professional Liability APPLICATION Architects & Engineers (Risk Placement Services, Inc.)

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MP 7004c 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 1 of 7
Miscellaneous Professional Liability
APPLICATION – Architects & Engineers
THIS APPLICATION IS FOR A COVERAGE PART WRITTEN ON A CLAIMS-MADE BASIS.
"CLAIMS" MUST BE FIRST MADE AGAINST ANY INSURED DURING THE "POLICY
PERIOD" OR ANY APPLICABLE EXTENDED REPORTING PERIOD, AND REPORTED TO
US AS SOON AS PRACTICABLE DURING THE "POLICY PERIOD", ANY SUBSEQUENT
RENEWAL OF THE POLICY OR ANY APPLICABLE EXTENDED REPORTING PERIOD. THE
INSURANCE FOR WHICH THIS APPLICATION IS MADE APPLIES ONLY IF THE "WRONGFUL
ACT" OUT OF WHICH THE "CLAIM" AROSE OCCURRED ON OR AFTER THE RETROACTIVE
DATE, IF ANY, SHOWN IN THE DECLARATIONS AND BEFORE THE END OF THE "POLICY
PERIOD". "DEFENSE EXPENSES" ARE PAYABLE WITHIN, NOT IN ADDITION TO, THE LIMIT OF
LIABILITY.
INSTRUCTIONS: Please complete the entire form. If there is insufficient space to complete an answer, please continue
on a separate sheet indicating the question number. If a section does not apply or is not relevant, answer “N/A” or “none”.
Information provided by you will be used by underwriters in determining the acceptability of adding the professionals to
the Miscellaneous Professional insurance coverage.
1. Applicant/Organization Name_____________________________________________________________________
2. Address of Organization_________________________________________________________________________
3. Address where specified professional(s) is located____________________________________________________
4. Type of entity:
Non Profit For Profit Other, Please describe:_____________________________________
5. What is the professionals working relationship with the Applicant/Organization?
Employee Volunteer Contractor
6. Are the Professionals requesting coverage:
Full Time Part time If Part Time, How many Hours per week do
they work on behalf of the Organization? __________ How many weeks per year? __________
7. Total Number of : Architects______________ Engineers____________ Other(Please describe)________________
8. What are the professional qualifications of the Architect(s) or Engineer(s) applying for coverage?
Licenses Held:_________________________
Professional Society Memberships:_________________________________________________
Length of time working as an Architect or Engineer:____________________________________
Length of time working with the Organization:_________________________________________
9. List States in which applicant is licensed?___________________________________________________________
Any foreign work?
Yes No If yes, please provide details:__________________________________________
____________________________________________________________________________________________
10. A)List the responsibilities/duties performed for the Organization (please be specific).
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
B
)List the responsibilities/duties performed for members, clients, and other third parties on behalf of the
organization.__________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
MP 7004c 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 2 of 7
Type of Services & Projects:
1. Do you or will you perform any of the following types of work on behalf of the Organization? (Indicate the proportion
of the specific service as it relates to the work performed for the Insured organization)
Feasibility studies, surveys where applicant is not involved in the design: Yes No ___________%
Design/Supervision of construction
Yes No ___________%
Supervision of construction only
Yes No ___________%
Boundary surveys
Yes No ___________%
Sewage systems
Yes No ___________%
Water systems
Yes No ___________%
Foundations
Yes No ___________%
Interior Design
Yes No ___________%
HV & AC
Yes No ___________%
Marine surveys
Yes No ___________%
Construction Managers:
Yes No ___________%
Machine Design
Yes No ___________%
Subsurface soil exploration
Yes No ___________%
Ground Testing or soil analysis
Yes No ___________%
Other(please describe):__________________________________________
Yes No ___________%
2. Do you or will you work on any of the following types of projects on behalf of the Organization? (Indicate the
proportion of the specific service as it relates to the work performed for the Insured organization)
Mines
Yes No ___________%
Harbors & Jetties
Yes No ___________%
Bridges & Tunnels
Yes No ___________%
Dams
Yes No ___________%
Nuclear & Atomic projects
Yes No ___________%
Petrochemicals, refineries, fertilizer, ammonia, urea plants
Yes No ___________%
Hospitals
Yes No ___________%
Schools
Yes No ___________%
Churches
Yes No ___________%
Industrial Buildings
Yes No ___________%
Commercial Buildings
Yes No ___________%
Municipal Buildings:
Yes No ___________%
Private Dwellings
Yes No ___________%
Condominiums, Highrise apartments
Yes No ___________%
Other(please describe):__________________________________________
Yes No ___________%
3. Does the applicant foresee any substantial changes in the percentages described in Questions #1 or #2 in the next
twelve months?
Yes No If yes, please describe:_______________________________________________
__________________________________________________________________________________________
4. Do you provide any other professional services on behalf of the Organization?
Yes No
If yes, please describe below:
____________________________________________________________________________________________
____________________________________________________________________________________________
5. What percentage of the applicant’s work performed for the Organization involves any of the following:
a) Subletting of work to others ___________%
Please describe what is sublet:____________________________________________________________
b) Professional services on projects for owners who act as their own builder: ___________%
c) Professional services on projects for packages or “Turnkey” contractors:
(1) as Manager of project ___________%
(2) as Member of project ___________%
6. Does the organization act as a General Contractor?
Yes No
7. Does the applicant or any subsidiary, parent or otherwise related entity engage in actual construction,
manufacturing, fabrication, or real estate development?
Yes No
8. Has the organization participated in a Joint Venture in the last five years? Yes No If yes, please provide
details on a separate page.
9. Does the organization use written contracts on every project?
Yes No If no, indicate percentage of services
that used non-written contracts in the last 12 months._________________________________________
MP 7004c 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 3 of 7
10. What percentage of services are rendered under AIA(American Institute of Architects) or other standard contracts?
Please specify if other standards are utilized. _______________________________________________________
11. When modified standard industry contracts, non-standard contracts, letter agreements, or other documents are
utilized, are they reviewed by the organizations legal counsel prior to execution?
Yes No
12. On projects where the applicant renders Construction Management Services, does the applicant use the American
Institute of Architects, or the Associated General Contractors Standard form of agreement between Owner and
Construction Manager?
Yes No If any other form of agreement is used, please submit a copy of form used.
13. What percentage of contracts contain limitations of liability provisions?__________%
14. List quality control measures and procedures that are employed by the organization?______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
15. List the three(3) largest current projects. Include project name, client(if applicable), location, services rendered,
billings, and value. ___________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
16. Have all known potential claims, incidents or suits, if any, been reported to your present carrier?
Yes No
17. Have any claims or suits been made during the past five years against the applicant, its predecessors in business,
any of the directors & officers of the Applicant organization or to the knowledge of the applicant against past
partners, past officers, or past directors of the applicant?
Yes No If yes, please provide full details:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
18. Is the applicant , after proper inquiry of each director, officer or partner of the applicant or other prospective insured
party, aware of any circumstance, incidents, situations or accidents that have occurred during the past five years
which may result in a claim being made against the applicant, his predecessors in business, or any present or past
partners, officers or directors of the applicant or organization?
Yes No If yes, please provide full details:
__________________________________________________________________________________________
__________________________________________________________________________________________
19. Is the applicant, or other proposed party for whom insurance is being requested, aware of any deficiencies in work
where he has performed professional services or deficiencies in work by others for whom the applicant is legally
responsible during the last five years?
Yes No If yes, please provide full details:
_________________________________________________________________________________________
_________________________________________________________________________________________
20. Has the applicant, or other proposed party for whom insurance is being requested, knowledge of injury to people or
damage to property during the last five years on or at a project where the applicant has rendered professional
services?
Yes No If yes, please provide full details:__________________________________________
_________________________________________________________________________________________
21. Is the professional applicant controlled, owned or associated with any other firm, corporation or company, other than
as stated above?
Yes No If yes, please provide full details:____________________________________
_________________________________________________________________________________________
MP 7004c 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 4 of 7
_________________________________________________________________________________________
22. Have you ever been convicted of a crime or felony?
Yes No
23. Provide information on your in-force professional Liability insurance. (if none exists, please indicate “none”)
a) Insurance Company Name ________________________________Expiration date _________________
b) Limits of Liability $______________________________________Policy # ______________________
c) Does your policy cover you while performing work for the agency/organization? Yes___ No___
d) Retroactive Date _______________________________________
MP 7004c 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 5 of 7
NOTICE TO APPLICANT – PLEASE READ CAREFULLY
FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED, AS AUTHORIZED AGENT FOR ALL
PERSONS AND ENTITIES PROPOSED FOR THIS INSURANCE, DECLARES THAT TO THE BEST OF
HIS/HER KNOWLEDGE THE STATEMENTS HEREIN ARE TRUE AND COMPLETE. THE INSURER IS
AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION. SIGNING THIS
APPLICATION DOES NOT BIND THE INSURER TO ISSUE, OR THE APPLICANT TO PURCHASE, ANY
INSURANCE POLICY.
THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH THE
INSURER. IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE
EFFECTIVE DATE OF THE POLICY, THE APPLICANT MUST NOTIFY THE INSURER, WHO MAY MODIFY
OR WITHDRAW THE QUOTATION.
THE UNDERSIGNED DECLARES THAT THE INDIVIDUALS AND ORGANIZATIONS PROPOSED FOR THIS
INSUR
A
NCE HAVE BEEN NOTIFIED THAT:
A. THIS POLICY APPLIES ONLY TO "CLAIMS" FIRST MADE OR DEEMED MADE AGAINST THE
INSUREDS DURING THE "POLICY PERIOD" OR EXTENDED REPORTING PERIOD, IF EXERCISED;
A
ND
B. THE LIMIT OF LIABILITY IS REDUCED BY AMOUNTS INCURRED AS "DEFENSE EXPENSES" AND
SUCH EXPENSES WILL BE SUBJECT TO THE DEDUCTIBLE AMOUNT.
(WORDS WITHIN QUOTATION MARKS ARE DEFINED IN THE INSURANCE POLICY.)
FRAUD STATEMENT
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.
FRAUD STATEMENT TO ALABAMA APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject
to restitution fines or confinement in prison, or any combination thereof.
FRAUD STATEMENT TO ARKANSAS 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.
FRAUD STATEMENT 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 settlement or award payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of regulatory agencies.
FRAUD STATEMENT 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.
MP 7004c 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 6 of 7
FRAUD STATEMENT TO FLORIDA APPLICANTS
Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of
claim or an application containing any false, incomplete or misleading information is guilty of a felony of the
third degree.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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 a denial of insurance
benefits.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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.
FRAUD STATEMENT 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.
FRAUD STATEMENT TO OREGON APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents materially false information in an application for insurance may be guilty of a crime and
may be subject to fines and confinement in prison.
MP 7004c 06 14
Copyright, American Alternative Insurance Corporation, 2013
Page 7 of 7
FRAUD STATEMENT 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.
FRAUD STATEMENT TO RHODE ISLAND 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, including failing to disclose whether
the applicant or applicants have been convicted of any degree of the crime of arson, is guilty of a crime and
may be subject to fines and confinement in prison.
FRAUD STATEMENT 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.
FRAUD STATEMENT TO VERMONT 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 may be a crime and subjects such person to criminal and civil penalties.
FRAUD STATEMENT 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.
FRAUD STATEMENT TO 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.
FRAUD STATEMENT TO 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.
______________________________________________ _______/_______/_______
Signature of Applicant Date
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Miscellaneous Professional Liability APPLICATION Architects & Engineers (Risk Placement Services, Inc.)

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Completed 23 November 2020

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