Specific excess coverage

Specific Job Excess Application

Insured's name*:
E-mail*:
Mailing Address:
City:
State:
Telephone*:
Name of project:
Name of client:
Describe your services for the project:
Provide the estimated beginning and completion dates for both the design and construction phases:
(Note : If construction has already started, coverage may not be available.)
Design Phase:	From To
Construction Phase:	From To
Total estimated construction value of the project:
Your total contract fees for this project:
Total estimated contract fees for all design firms for this project:
Are you the prime design firm on the project?	Yes No
What coverage limits should be quoted:
Are you aware of any claims on this project, as described below?	Yes No
If Yes, complete a Claim Questionnaire for each claim.
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).
Name:
Title:
Date of Application: