Small firm coverage

ARCHITECTS/ENGINEERS
SMALL FIRM APPLICATION


FIRM PRACTICE

NEW APPLICANT RENEWAL CLIENT

Your firm's practice is best described as an architectural, engineering or environmental firm. It is not a geotechnical engineering, marine or naval architectural firm or laboratory.		Yes No
Your firm meets all of the following requirements: A principal of the firm is licensed/registered in the appropriate discipline The principals derive their primary source of income from the firm. The firm and/or principals have never been involved in revocation of license, disciplinary action nor recent bankruptcy. The firm's gross receipts for each of the last three complete fiscal years and projected fiscal year are $500,000 or less.		Yes No
In the past three years, and for projected year, did your firm:

Engage in design-build (as the prime on a design-build project); retain contractors and/or subcontractors; perform construction, manufacturing, fabricating, real estate development or project financing or have financial interests in organizations that do?		Yes No
Perform Construction Management services? (This does not include construction phase services on projects you designed.)		Yes No

Questions 5 and 6 do not apply to firms with no prior coverage. If the firm does not have retroactive coverage, please check "No."

Contract with more than 10% uninsured design professional subconsultants?		Yes No
Enter into more than 10% of projects without written contracts?		Yes No
Have more than one professional liability claim or have one claim that is reserved or paid in excess of $10,000?		Yes No
Perform services on: a. Ski lifts, amusement rides? b. Residential condominium projects, planned unit developments or time-share projects? c. Any projects involving design of any building, system or component intended to be manufactured or used on more than one project without site adaptation? d. Preliminary site assessments, asbestos abatement, parking garages, retirement homes, convalescent hospitals, correctional institutions or buildings over 15 stories?		Yes No Yes No Yes No Yes No
Perform services accounting for more than 25% of gross receipts on: a. Sports facilities, arenas, convention facilities, grandstands, theaters, amusement parks, transportation passenger terminals (excluding interior design and landscape design services), wastewater/sewage treatment plans or systems or environmental remediation projects? b. Mines, quarries, tunnels, bridges or trestles? c. Structures for offshore or marine use, harbors, jetties, docks, piers, wharves?		Yes No Yes No Yes No
Comments:

FIRM PROFILE

1. Firm Information

Firm's full name*:

Street Address:

Mailing Address:

City: State: Zip Code:

Telephone*:

Facsimile:

E-mail*:

2. Main Office and Branches

Percentage of GROSS RECEIPTS earned in main office and branches:

City

State

Zip Code

% of Fees

Main Office

Branch 1

Branch 2

3. Firm Personnel

Please enter the number of personnel in your firm divided as indicated:
(Include each individual in only one category)

a. Principals:

(Do not include below.)

b. Professionals:

(project managers, architects, engineers, scientists)

c. Technical:

(CAD operators, drafting, field, laboratory)

d. Administrative
& Other

PERSONNEL TOTAL

4. Firm Ownership

Date your firm was established:

Entity Type:

Individual

Sole Proprietor

Partnership

LLP

Joint Venture

Corporation

LLC

Other

If "Other" then please describe:

Does your firm have any pre-existing entities? Yes No

Do any other entities, or individuals not employed by your firm, have any ownership
interest in your firm? Yes No

Does your firm or do any partners, principals or officers own any interest in any other entity? Yes No

Are professional services provided by your firm to any entity in which your firm, or your partners, principals or officers, maintains a cumulative ownership interest greater than ten percent (10%)? Yes No

Comments:

5. Financial Information

Please 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 no 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 year
	Two years ago
	Three years ago

If your firm has four years of fee history, do you wish to be considered for a 2-year policy term?	Yes No
If no, do you wish to be considered for Policy Limits of $1,000,000 / $2,000,000 and $2,000,000?*	Yes No
If yes, do you wish to be considered for Policy Limits of $500,000 / $1,000,000 and $1,000,000?*	Yes No

* Maximum Available Limits:
1-year term - $1,000,000 ($2,000,000 available with underwriter approval)
2-year term - $500,000 ($1,000,000 available with underwriter approval)

6. Subconsultants

Provide the percentage of your firm's GROSS RECEIPTS that were paid during the last year to subconsultants that have professional liability insurance.

Subconsultants	Insured for Professional Liability
Structural engineering
Other professional services


Comments:


PROJECTS

What percentage of your firm's GROSS RECEIPTS during the last fiscal year were attributable to:

	Feasibility, programming, planning or economic studies?
	Restaurants; office, warehouse, processing, manufacturing and production buildings?
	Roads/highways?
	Utilities?
	Sports facilities, arenas, convention facilities, grandstands, theaters, amusement parks, transportation passenger terminals (excluding interior design and landscape design services), wastewater/sewage treatment plans or systems or environmental remediation projects?
	Mines, quarries, tunnels, bridges or trestles?
	Structures for offshore or marine use, harbors, jetties, docks, piers, wharves?
(Total cannot exceed 100%. For e., f., g., each cannot exceed 25% of gross receipts.

DISCIPLINES

Provide the percentages, based on your firm's GROSS RECEIPTS, attributable to the following disciplines provided by your firm (do not include percentages from work performed by your subconsultants).

Estimated current year	Last 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
		Environmental engineering
		DISCIPLINES TOTAL (must equal 100%)

Comments:


CLAIMS & INSURANCE

CLAIMS

In the last three years, has your firm had a claim against your practice, or against you on a project policy, as described below? If yes, complete a Claim Questionnaire for each claim.	Yes No

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 an 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.).

For firms in business for five or more years, has your firm been claim-free for the past five years?	Yes No N/A


INSURANCE

Provide the following information about your firm's professional liability insurance for the current year:

None. Your firm currently has no professional liability insurance.

Policy Start:
Policy End:
Insurance Company:
Limits of Insurance:
Deductible:
Premium:
Retroactive Date:
Comments:


FRAUD WARNINGS, CLAIMS REPRESENTATION, SIGNATURE

CLAIMS-MADE BASIS
This application is for professional liability insurance that is provided on a claims-made basis. The policy applies to claims arising out of your professional services performed on or after any retroactive date shown in the policy, and is subject to all policy terms, conditions, declarations and endorsements.

EXPENSE WITHIN LIMITS
The policy contains a provision permitting claim expenses, including legal defense costs, to be applied against the deductible. Subject to restrictions in the certain states, the payment of claim expenses reduces the limits of insurance available to pay claims and the company has the right to designate legal counsel and uses panel counsel, as needed for claims covered by any insurance provided.

FRAUD WARNING
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.

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 in the CLAIMS section above. 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 specifically accepted by the Company.

REPRESENTATION INFORMATION
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.

Signature:
Name:
Title:
Date of Application:
Agent Name:
License Number: