Architect/Engineer/Environmental Consultant Professional Liability Insurance

Architects / Engineers / Environmental Consultants (A/E/E) Application
Firm's name* :
Street address :
Mailing address :
City : State : Zip :
Telephone* : Facsimile :
E-mail* :
FIRM PROFILE
*1 Date your firm was established :
month : day : year :
Sole proprietorship	Partnership
Corporation	Joint venture
Limited liability corporation	Limited liability partnership
Other (describe)


*2 List all pre-existing entities, including acquisitions and mergers, and their dates of existence :
Dates (from/to) /
Dates (from/to) /

3 Number of personnel :
Principals (Do not include below)
Professionals (project managers, architects, engineers,scientists)
Technical (CAD operators, drafting, field, laboratory)
Non-Technical (equipment operators and other field personnel)
Administrative and other
Total

*4 List all professional societies and associations to which your firm and KEY PERSONNEL belong :

5 If your firm has field technicians, list certifications : (e.g., ACI,CHMM,CWI,NICET,OSHA : 40-hour, etc.)

6 If your firm has a laboratory, list accreditation's : (e.g., A2LA,AASHTO, state EPA, ISO, etc.)

7 Do any other entities, or individuals not employed by your firm, have any ownership interest in your firm? Yes No
If yes, list the owners and indicate their percentage of interest in your firm.

8 Does your firm or any KEY PERSONNEL own any interest in any other entity? Yes No
If yes, list the owner, amount of ownership, name of entity, relationship to your firm, nature of activities and the entity's GROSS RECEIPTS during the last complete year

9 Are professional services provided by your firm to any entity in which your firm or KEY PERSONNEL maintain a cumulative ownership interest greater than ten percent (10%)? Yes No
If yes, complete the Entity Ownership Questionnaire.

10 Provide your firm's GROSS RECEIPTS attributable to the following years. (Include all receipts for projects insured by project policies within the GROSS RECEIPTS column and list separately in the Project Policy Receipts column.) GROSS RECEIPTS means the EXACT dollar amount of your firm's gross revenues, but not including interest income, rental income on real estate, or sales and service taxes.

Fiscal year end (month/day/year)	GROSS RECEIPTS	Project Policy Receipts*
/ / Estimated Current Year
/ / Last Complete Year
/ / Two Years Ago
/ / Three Years Ago
*Complete Project Insurance Questionnaire
To be considered for a multi-year policy premium quotation, provide your firm's projected GROSS RECEIPTS for next year :

11 List all office locations with a contact name and the percentage of your firm's GROSS RECEIPTS derived from each location for the last complete year : street address, city, state, zip, contact name.
			%
			%
			%
			%
			100 %

12 Provide the percentages of your firm's GROSS RECEIPTS that were paid to subconsultants and subcontractors during the last complete year. N/A
Subconsultants	Insured for Professional Liability	Not Insured for Professional Liability
Structural Engineering	%	%
Environmental services*	%	%
Other professional services	%	%
* As described within Environmental Services in question 14 C.

Subcontractors (environmental only)	Insured for Contractors Pollution Liability (CPL)	Not Insured for Contractors Pollution Liability (CPL)
Field services (drilling, sampling,testing)	%	%
Site remediation activities	%	%
Asbestos, lead or radon abatement	%	%


13 Does your firm obtain the appropriate certificates of insurance? N/A
From your consultants Yes No
From your prime professionals Yes No
From your subcontractors Yes No

SERVICES

14 Provide the percentage of your firm's GROSS RECEIPTS attributed to the following services during the last complete year.
A. Design and Other Related Services (non-environmental)
1. Design services
% a. Total of all design services	%Percentage with construction observation %Percentage without construction observation 100%
2. Non-design services
% a. Quantity or cost estimates without design
% b. Plan checking without design
% c. Building commissioning (quality assurance process as a separate service)
% d. Feasibility, programming, planning, economic or seismic studies
% e. Architectural master planning
% f. Forensic inspections, expert witness services, failure analysis

3. Field services
% a. Construction observation without design
% b. Inspection as a stand-alone service
% c. Boundary and construction staking
% d. Construction materials testing (including compaction testing)
% e. Drilling and sampling (geotechnical)

% 4. Laboratory analysis (including soils and construction materials, but not environmental)
% 5. Other (describe)


B. Operation and Management Services (of these facilities)
% 1. Domestic water, utility, building, other facilities
% 2. Wastewater treatment plants, landfills, chemical processing plants (describe)

% 3. Other (describe)

C. Environmental Services
1. Environmental engineering (detection, determination and remediation of contaminated sites)
% a. Preliminary site assessments (PSA-Phase I)
% b. Other environmental assessments (compliance audits, environmental impact studies)
% c. Investigations (drilling and sampling, Phase II)
% d. Studies (feasibility, siting, closure, hydrogeological, hydrological)
% e. Asbestos and lead studies (inspection, identification, work plans)
% f. Asbestos and lead abatement
% g. Design services (remediation, environmental facilities, pollution control systems)
% h. Site remediation activities and remediation observation or management
% i. Environmental project observation/oversight (non-remediation)
(describe)

2. Environmental sciences
% a. Permitting
% b. Industrial hygiene
% c. Laboratory analysis (chemical and analytical)
% d. Environmental training and manuals for other than internal usage
% e. Fish and wildlife or botanical studies, including wetland delineation
% f. Forensic inspections, expert witness services

3. Other environmental services (describe)
%

DISCIPLINES
15 Provide the percentages, based on your firm's GROSS RECEIPTS, attributable to the following disciplines provided by your firm, excluding your subconsultants.

Last Complete
Year

ARCHITECTURE

Architecture

Architectural planning (including master planning)

Interior design and graphics

Landscape architecture

ENGINEERING

Structural engineering

Civil engineering

Civil wastewater engineering (municipal, non-industrial)

Land surveying

Traffic engineering

Mechanical engineering

Acoustical engineering

Process engineering

Electrical engineering

Illumination engineering

Geotechnical engineering (soil mechanics for structures)

Geotechnical field services and construction materials testing (including drilling)

LABORATORY

Construction materials testing (non-environmental)

Environmental (analytical)

Conformity assessment* (product testing and materials science)

Life sciences* (clinical research - not diagnostic medical labs)

Microbiology and analytical chemistry* (food, drugs, personal care products)

*Complete Laboratory Questionnaire

ENVIRONMENTAL

Environmental engineering (including mines and mining waste treatment) - See question 14C

Environmental science - See question 14C

Industrial wastewater engineering (non-municipal)

Geo-environmental engineering (including landfills, waste treatment and retention ponds)

OTHER

Marine engineering (describe)

Naval engineering (describe)

Other (describe)

100%

PROJECTS

16 Provide the percentage of your firm's GROSS RECEIPTS attributable to the following projects during the last complete year.

HIGH RISE

All buildings over 15 stories (DO NOT classify these below.)

Do any of these buildings include residential condominiums?

RESIDENTIAL

Residential condominiums

Planned Unit Developments (PUDs)

Single-family residential subdivisions

Custom homes

Apartments

INSTITUTIONAL

Hospitals, retirement homes, convalescent hospitals

Public schools, colleges and universities

Churches

Correctional institutions

INDUSTRIAL

Processing, manufacturing and production systems

Mines, quarries, tunnels

Oil refineries

Chemical plants and pipelines

Facilities related to nuclear activities

GENERAL BUILDING

Parking garages

Hotel

Motels

Retail, malls, shopping centers

Office, warehouse, processing, manufacturing and production buildings

Restaurants

RECREATIONAL FACILITIES

Sports facilities, arenas, convention facilities, grandstands, theaters, amusement parks (describe your services for each)

Ski lifts, amusement rides (describe your services for each)

INFRASTRUCTURE

Utilities

Roads and highways

Airport runways

Transportation passenger terminals (describe your services)

Structures for offshore or marine use, harbors, jetties, docks, piers, wharves

Bridges, trestles

Dams, reservoirs, levees

Landfills

Wastewater, sewage and water treatment systems

Waste treatment, storage or disposal facilities

OTHER

All other environmental projects (including remediation sites, e.g., National Priorities List, Superfund and UST)

Other (describe)

CLIENTS

17 Provide the percentage of your firm's GROSS RECEIPTS attributed to the following types of clients during the last complete year.

Private sector :

Owners

Developers

Contractors

Design professionals

Environmental consultants

Other (describe)

Public sector

Foreign

100%

PROJECT DELIVERY METHODS

18 Provide the percentage of your firm's GROSS RECEIPTS attributable to projects delivered in the following manner during the last complete year.

Design-Bid-Build (traditional delivery method)

Design-Build (submit Design-Build Questionnaire)

Fast Track (describe)

Turnkey (describe)

Construction management*

*Do you perform any construction activities or hire contractors? Yes No

*During the last year, was your firm, or any subconsultant or subcontractor to you, responsible for construction means, methods, techniques, procedures, or job safety?
Yes No

If yes to either question above, explain and provide details about your firm's GROSS RECEIPTS attributable to these services and a copy of the contract. If you use unmodified standard professional association forms, provide form numbers only, not copies.

ABANDONED PROJECTS

19 Does your firm wish to report (or reinstate) any permanently abandoned projects that were originally intended for construction and where design receipts were generated this year or within the last three years? (Do Not include master planning projects, feasibility studies or inspections.)

Yes No

If yes, complete the Abandoned Projects Questionnaire, if not previously submitted to us.

BUSINESS PRACTICES

*20 Do your firm's quality control procedures include:

A written quality control manual Yes No

Procedures for reviewing all client and subconsultant contracts before they are signed Yes No

Use of specification and design checklists as well as procedures for their review Yes No

Procedural or technical manuals for both in-house and field personnel
Yes No

Continuing education and training programs for professional and technical personnel Yes No

*21 Has your firm completed an organizational peer review through a professional association? Yes No

If yes, when and by whom?

22 Provide the percentage of your firm's GROSS RECEIPTS derived from the following during the last complete year.

Your firm's standard contract form (attach copy)

Your firm's letter of agreement (attach copy)

A professional association contract form

Your client's contract form *

Your client's purchase order form *

Verbal agreements **

Other (describe)

100 %

* Describe what steps your firm takes to protect itself against unfavorable contract language.

** Describe what steps your firm takes to confirm agreement by all parties.

*23 Does your firm enter into contracts which give ownership of your documents to clients?

Yes No

If yes, do you use a written disclaimer regarding reuse of those documents?

Yes No

24 Does your firm design any building, system, or component that is intended to be used for more than one location without adaptation?

Yes No

If yes, describe

25 Does your firm use a limitation of liability provision in its contracts? Yes No

If yes, complete the Limitation of Liability Report for possible premium credit.

CLAIMS

26 In the last five years, has your firm had a claim against your practice, or against you on a product policy, as described below?

Yes No If yes, complete a Claim Questionnaire for each claim.

(Renewal clients need only complete a Claim Questionnaire for any claim not reported to us during their policy period.)

Claim means : (a) a demand against you for money or services, or the filing of a suit or the initiation of an arbitration proceeding naming you, seeking damages for all alleged error, omission, negligent act : or (b) an event, a circumstance, an incident, or unresolved fee dispute, of which you have knowledge that may result in a claim as described in (a).

INSURANCE

27 Identify your firm's current commercial general liability insurance company :

Expiration date : Policy limits :

*28 Provide the following information about your firm's professional liability insurance : None

	Policy Period (from/ to)	Insurance Company	Limits of Insurance	Deductible	Premium
Current yr			$	$	$
Last yr			$	$	$
2yr ago			$	$	$
3yr ago			$	$	$
4yr ago			$	$	$
Retroactive date on current policy :

QUOTATION OPTIONS

29 Indicate which options your firm wishes quoted for professional liability insurance :

Combined Single/ Aggregate Limit	Split Limits Per Claim/ Aggregate	Deductible Per Claim
$250,000	$250,000/500,000	$5,000
$500,000	$500,000/1,000,000	$10,000
$1,000,000	$1,000,000/2,000,000	$15,000
$2,000,000	$2,000,000/4,000,000	$25,000
$3,000,000	$3,000,000/5,000,000	$50,000
$4,000,000
$5,000,000
Shared Cost of Defense Dollar One Defense

ADDITIONAL INFORMATION

30 Provide any information that will further our understanding of your firm.

FRAUD WARNING

Arkansas - 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.

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 - 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.

New York - 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.

Ohio - Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma - Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of any insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania - Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claims 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.

CLAIMS REPRESENTATION / SIGNATURE

I specifically asked all principals and project managers in our firm if they have knowledge of any claim or potential claim against us that is not listed in our response to question 14. There are none.

If we become aware of any claim or potential claim against us, before the inception of coverage, we will immediately inform the Company, Agent or Broker. We understand that any claim or potential claim against us, before the inception of coverage, whether identified to the Company or not, will not be covered by this insurance unless specially accepted by the Company.

On behalf of our firm, I agree that this application, including all attachments and exhibits, is complete and correct to the best of my knowledge and belief. I understand that this application forms the basis of the contract of insurance, if the Company offers coverage and we accept the Company's offer. I also understand that completion of this application does not bind the Company, Agent or Broker to provide insurance.

Name of Principal,Partner, or Officer :

Title : Date of application :