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THE INFORMATION BEING REQUESTED IS FOR A CLAIMSMADE (Travelers Insurance)

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DPL-F-14100 Rev. 04-15

DESIGN PROFESSIONALS LIABILITY COVERAGE

APPLICATION

Travelers Casualty and Surety Company of America

THE INFORMATION BEING REQUESTED IS FOR A CLAIMS‐MADE POLICY. IF ISSUED, THE

POLICY WILL APPLY ONLY TO CLAIMS FIRST MADE OR DEEMED MADE DURING THE

POLICY PERIOD OR ANY APPLICABLE EXTENDED REPORTING PERIOD. THE LIMIT OF

LIABILITY AVAILABLE TO PAY CLAIMS WILL BE REDUCED AND MAY BE EXHAUSTED BY

THE AMOUNTS PAID AS DEFENSE EXPENSES. THE DEDUCTIBLE WILL APPLY TO DEFENSE

EXPENSES.

IMPORTANT NOTE – NEW YORK: DEFENSE EXPENSES WILL REDUCE UP TO 50% OF THE

LIMIT OF LIABILITY, AND MAY BE APPLIED TO UP TO 50% OF THE DEDUCTIBLE.

Answer each question on behalf of all entities seeking insurance coverage, unless specifically requested otherwise.

An Additional Information section is provided at the end of this document for any information that exceeds the space provided.

GENERAL INFORMATION

Proposed Named Insured:

Today's Date:

"Trade" or "Doing Business As" Name(s):

Mailing Address:

Street:

City: State: Zip Code:

Physical Address (if different):

Street:

City: State: Zip Code:

Primary Contact Name and Title:

Telephone Number:

Email Address:

Web Address:

Type of Legal Entity:

Individual General Partnership Limited Partnership

Corporation Limited Liability Company Other:

Proposed Effective Date (mm/dd/yyyy):

Date Business Started:

APPLICANT INFORMATION

1. Indicate number of firm personnel:

Number of

Full-Time

Staff

Number of

Part-Time

Staff

Number of Registered Architects,

Landscape Architects, Land

Surveyors, and Licensed Engineers

Number Who Attended Training or a

Seminar on Professional Liability Risk

Management in the Past 12 Months

Princi

als/Mana

emen

ees

DPL-F-14100 Rev. 04-15

NEW FIRMS WITH NO HISTORICAL DATA SHOULD COMPLETE ALL QUESTIONS BASED UPON PROJECTIONS FOR THE

FIRST YEAR IN BUSINESS

2. Indicate annual gross billings:

Most Recently

Completed Fiscal Year:

/ to /

MO/YR MO/YR

One Fiscal Year

Prior:

/ to /

MO/YR MO/YR

Two Fiscal Years

Prior:

/ to /

MO/YR MO/YR

Next 12 Months

Projected:

/ to /

MO/YR MO/YR

Billings Passed to Sub

consultants Carrying Their Own

Professional Liability Insurance

$ $ $ $

ll Other Annual Billin

s* $ $ $ $

Total Annual Gross Billin

s $ $ $ $

*Billings for non-professional services or expenses that are reimbursed under the terms of your client contract should not be included.

3. What percentage of annual gross billings from the most recently completed fiscal year were derived

from contracts solely related to feasibility studies, master planning, reports, opinions, non-structural

interior design, or forensic engineering?

4. Provide the percentage of annual gross billings for the most recently completed fiscal year attributable to the following

disciplines, excluding billings to subconsultants. For unlicensed construction and design consultants, such as

acoustical consultants, please specify your discipline in “Other”.

Discipline

% Of Annual

Gross Billings

Discipline

% Of Annual

Gross Billings

enc

Construction Mana

er % Interior Desi

ner %

Architect % Landscape Architect

Civil En

ineer % Land Surve

or %

Electrical En

ineer % Mechanical En

ineer %

Environmental Consultant* % Process En

ineer %

Forensic En

ineer % Structural En

ineer %

Geotechnical En

ineer % Other

lease s

ecif

: %

*Complete the Environmental Additional Information Request

5. Provide the percentage of annual gross billings for the most recently completed fiscal year derived from each of the

following project types. Please use whole numbers only.

Project Type

% Of

Annual

Gross

Billings

Project Type

% Of

Annual

Gross

Billings

irports % Military Facilities

musement Parks/Zoos % Mines/Quarries

Apartments (do not include condominiums

or cooperatives)

% Museums/Libraries

sbestos/Mold/Radon/Lead Abatemen

% Nuclear Facilities

Bridges (spans < 500 ft.) % Parking Garages

Bridges (spans > 500 ft.) %

Parks/Playgrounds/Sports

Building Façade Restoration

Inspection % Power Generation/Distribution %

Civil/Site Development

–

Non-Residential % Public Safety/Police/Fire Stations %

Civil/Site Development - Residential % Refinery/Petrochemical %

Commercial/Office/Retail/Banks (>15 stories) % Religious Facilities %

Commercial/Office/Retail/Banks (<15 stories) % Roads/Highways %

Condominiums

–

Commercial % Single Family Homes %

Condominiums

–

Residential % Stadiums/Arenas/Convention Centers %

DPL-F-14100 Rev. 04-15

Project Type

% Of

Annual

Gross

Billings Project Type

% Of

Annual

Gross

Billings

Cooperatives

–

Residential % Swimming Pools %

Education/Schools % Telecommunications/Cabling %

Harbors/Piers/Ports % Townhouses %

Hospitals/Healthcare/Assisted Living Facilities % Toxic/Hazardous Waste Sites %

Hotels/Motels % Tunnels/Dams/Levees %

Industrial/Manufacturin

% Under

round Stora

e Tanks %

Jails/Prisons/Detention Centers % Water/Sewer Pipelines %

Judicial Courts %

Water/Wastewater Treatment

Plants/Facilities - Industrial

Laboratories/Clean Rooms

Water/Wastewater Treatment

Plants/Facilities

–

Municipal

Landfills % Other (please specify): %

6. Has the applicant firm, any subsidiary, or any predecessor rendered services in the past 3 years, or

do they expect to render services in the next 12 months, for any project where all or a portion of the

project is currently titled, or is expected to be sold, under a condominium or cooperative form of

ownership? (Note: Do not include

services provided for the owner of a single condominium

or co-op unit) ................................................................................................................................................

Yes No

If yes, please provide the firm’s total gross annual billings derived from condominium

and cooperative projects below. Include 100% of the billings for projects where all or a portion of the

project is currently titled, or expected to be sold, under a condominium or cooperative form of ownership.

Most Recently

Completed Fiscal Year:

/ to /

MO/YR MO/YR

One Fiscal Year

Prior:

/ to /

MO/YR MO/YR

Two Fiscal Years

Prior:

/ to /

MO/YR MO/YR

Next 12 Months

Projected:

/ to /

MO/YR MO/YR

Condominium Pro

ects $ $ $ $

Coo

erative Pro

ects $ $ $ $

7. For the five largest projects based on construction value over the past three years, provide:

Project Name Location Services Rendered Project Type

Construction

Value

Fees

Billed

$ $

8. In the most recently completed fiscal year, what percentage of your annual gross billings were derived from the

following clients:

Firm’s Client

% Of Annual

Gross Billings

Firm’s Client

% Of Annual

Gross Billings

Contractors

% Private Owners

Design Professionals

% State or Local Governments

Developers

Other(please specify):

DPL-F-14100 Rev. 04-15

Federal Government

Other(please specify):

Non-Profit Entities

% Total 100%

9. What percentage of annual gross billings from the most recently completed fiscal year were derived fro

eat clients?

10. Is more than 50% of annual gross billings from the most recently completed fiscal year derived

from one client? ..........................................................................................................................................

Yes No

If yes, please provide details in the Additional Information section at the end of this application.

11. What percentage of annual gross billings from the most recently completed fiscal year were

derived from projects located outside the U.S., its territories, or possessions ?

Provide the following for the three largest current or proposed foreign projects:

Project Name Location Services Rendered Project Type

Construction

Value

Fees

Billed

$ $

12. Is the firm, or any parent, subsidiary, or other related organization domiciled outside of the U.S.,

its territories, or possessions? ....................................................................................................................

Yes No

13. Does any partner, principal, member, officer, director, shareholder, or immediate family member have

an ownership interest in any entity for whom professional services are rendered? ...................................

Yes No

If yes, please provide details in the Additional Information section at the end of this application.

14. Is the firm or any parent, subsidiary, or other related organization engaged in any of the following:

a. Actual construction, fabrication, installation, or erection? ...................................................................

Yes No

b. Real estate development? ..................................................................................................................

Yes No

c. Designing, manufacturing, selling, leasing, or distributing any other product, process, or

patented design? ...................................................................................................................................

Yes No

If yes to any of the above, please attach sample contracts and provide details, including relationships,

description of services rendered, construction values, and fees received in the Additional Information

section at the end of this application.

15. Does the firm or any parent, subsidiary, or other related organization ever have single-point

responsibility for both the design and construction of a project? ...............................................................

Yes No

If yes, please complete the Design/Build Additional Information Request.

16. Has the firm or any subsidiary or predecessor firm ever filed for, or been in, receivership or bankruptcy? Yes No

If yes, please provide details in the Additional Information section at the end of this application.

RISK MANAGEMENT

17. For all contracts used in the most recently completed fiscal year, provide the breakdown of contracts used by type:

Type Of Contract % All Contracts Type Of Contract % All Contracts

Professional Association Contract % Letter of A

reemen

Client Drafted Contrac

% Verbal A

reement %

Purchase Order % Other

lease s

ecif

: %

Firm’s Drafted Contrac

% Total 100%

18. Is a limitation of liability provision incorporated into contracts and agreements? ...................................... Yes No

If yes, what percentage of contracts contain a limitation of liability clause less than or equal to $250,000?

19. Provide the breakdown of design services based on annual gross billings from the most recently

completed fiscal year:

a. Percentage with construction observation:

b. Percenta

e without construction observation:

DPL-F-14100 Rev. 04-15

20. Do you use a written contract with all subconsultants? .............................................................................. Yes No

If no, please explain:

21. What percentage of your accounts receivable are more than 90 days past due?

22. In the past three years has any suit been brought against any client to collect fees? ............................... Yes No

If yes, please provide details including date of suit, circumstances, amount of fees, and whether or not

any counter-suits or allegations were made or brought in the Additional Information section at the end of

this application.

PRIOR INSURANCE AND CLAIM HISTORY

23. Has any claim involving professional services been made against any of the following during the past

five years (ten years if gross annual billings are greater than $5 million), or earlier if still pending:

a. You, your firm, or any member of your firm? .......................................................................................

Yes No

b. Any predecessor firm? .........................................................................................................................

Yes No

c. Any former member of your firm or a predecessor firm for professional services while a

member of such firm? ..........................................................................................................................

Yes No

24. Do you or any person seeking coverage under this proposed policy have knowledge of any incident,

act, error, or omission involving professional services that could reasonably be expected to be the

basis of a claim? .........................................................................................................................................

Yes No

If yes to any part of question 23 or 24, please complete a Claim, Suit, or Incident Additional Information

Request for each claim, incident, act, error, or omission.

ATTACH A COPY OF THE FIRM’S PROFESSIONAL LIABILITY LOSS RUNS FOR THE PAST FIVE YEARS

(TEN YEARS IF GROSS ANNUAL BILLINGS EXCEED $5 MILLION)

25. Complete the following chart for professional liability insurance coverage carried during the past five years:

(Check here if none:

)

Carrier Policy Period

Per Claim Limit

Of Liability

Aggregate Limit

of Liability

Deductible

Amount Premium

Retroactive

Date

Current year to $ $ $ $

Prior Year 1 to $ $ $ $

Prior Year 2 to $ $ $ $

Prior Year 3 to $ $ $ $

Prior Year 4 to $ $ $ $

26. Provide the following for general liability insurance coverage currently in force (Check here if none ):

Carrier Policy Expiration Limits of Liability

27. Has any person or entity seeking professional liability insurance ever been declined or had

such insurance nonrenewed or cancelled, including for nonpayment of premium?

(Missouri applicants: Do not complete) ......................................................................................................

Yes No

If yes, please provide details in the Additional Information section at the end of this application.

COMPENSATION NOTICE

Important Notice Regarding Compensation Disclosure

For information about how Travelers compensates independent agents, brokers, or other insurance producers, visit this

website:

http://www.travelers.com/w3c/legal/Producer_Compensation_Disclosure.html

If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Travelers, Agency

Compensation, One Tower Square, Hartford, CT 06183.

This application, including any material submitted in conjunction with this application or any renewal of any policy issued,

does not amend the provisions or coverages of any insurance policy or bond issued by Travelers. It is not a

DPL-F-14100 Rev. 04-15

representation that coverage does or does not exist for any particular claim or loss under any such policy or bond.

Coverage depends on the facts and circumstances involved in the claim or loss, all applicable policy or bond provisions,

and any applicable law. Availability of coverage referenced in this document can depend on underwriting qualifications

and state regulations.

FRAUD WARNINGS

ALABAMA, ARKANSAS, DISTRICT OF COLUMBIA, MARYLAND, NEW MEXICO, AND RHODE ISLAND: Any person who

knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD)

presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

COLORADO: 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.

FLORIDA: 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.

KENTUCKY, NEW JERSEY, NEW YORK, OHIO, AND PENNSYLVANIA: 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. (In New York, the civil penalty is not to exceed five thousand dollars

($5,000) and the stated value of the claim for each such violation.)

LOUISIANA, MAINE, TENNESSEE, VIRGINIA, AND WASHINGTON: 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.

OREGON: 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 may be guilty of a crime and may be subject to fines and confinement in prison.

SIGNATURES

I declare that I have examined this application and accompanying supplements and materials, and to the best of my

knowledge and belief, after reasonable inquiry, they are true, correct, and complete, and may be relied upon by Travelers.

I understand that if any of this information changes prior to the issuance of the insurance applied for that I am obligated to

notify Travelers of such changes and that Travelers may modify or withdraw any proposal for insurance. Travelers is

authorized to make inquiry in connection with this application.

Authorized Representative Signature:*

(Principal, Officer, or Shareholder)

Authorized Representative Name - Printed: Date (mm/dd/yyyy):

Producer Signature:**

State Producer License No.: Date (mm/dd/yyyy):

Agency:

Agency Contact:

Agency Phone Number:

* If you are electronically submitting this document, apply your electronic signature to this form by checking the Electronic Signature and

Acceptance box below. By doing so, you agree that your use of a key pad, mouse, or other device to check the Electronic Signature and

Acceptance box constitutes your signature, acceptance, and agreement as if actually signed by you in writing and has the same force

and effect as a signature affixed by hand.

Electronic Signature and Acceptance – Authorized Representative

Electronic Signature and Acceptance – Producer

**Producer information only required in Florida and Iowa.

ADDITIONAL INFORMATION

This area may be used to provide additional information to any question. Reference the question number.

Fillable THE INFORMATION BEING REQUESTED IS FOR A CLAIMSMADE (Travelers Insurance)

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