Architects & Engineers Professional Liability

Basic Information

1. (a) Firm Name(s):

 

(b) Firm Address(es):

 

(c) Phone:

(d) Fax:

(e) E-mail:

(f) Tax ID# :

2. Description of our practice:


3. Gross billings for past three (3) fiscal years (Include consultants fees you pass on to others, uncollected fees and reimbursable expenses):
Dates: (Most recent completed)      Gross Billings
                        $
                        $
                        $

Firm Details

4. Year our firm was established in:

5. We have had a claim made against us in the past five years:

6. We currently carry Professional Liability Coverage : 

7. Our insurance company is:

8. Our current policy expires on:

9. We have continuously carried coverage for:

10. We have a policy endorsement giving full prior acts coverage:

11. Retroactive coverage date in current policy:


12. If you have had a claim (or incident with a payment by the insurance company) please give a brief description of the claim including your services, the claimant's name, the amounts paid to defend and indemnify you (or the company reserve on an open claim), the date the claim was made, the date it settled, and any other useful information.  If the company's claim is not settled, we need an analysis of liability by the attorney appointed by your insurance company.



13. Please provide full details if any of the principals, partners, officers, directors, shareholders or employees have knowledge of any circumstance that is or could be the basis for a claim under the proposed insurance policy.


Practice Emphasis

14. Please indicate the approximate percentage of the most recent gross billings, if any, derived from the following categories:

(a) Feasibility Studies:

%

(b) Reports:

%

(c) Opinions:

%
(d) Non-structural Interior Designs: %
(e) Master Plans: %
(f) Landscape Architecture: %
(g) Land Surveying: %
(h) Direct Reimbursables %
15. Please indicate the billings reported for the most recent fiscal year for projects insured under separate project policies $
16. Estimated gross billings for upcoming fiscal year: $
 

17. Members of our firm belong to:


 

18. We have selected the service type and project code(s) that best describe the majority of our practice. If available, attach a brochure to help us understand you practice:

Service Code:

Project Codes


If Other, please describe:

If Other, please describe:
19. We have total staff.  They are categorized as follows:
(Show part time staff as "1/2")

Licensed Architects

Licensed Engineers

Technical Staff

Administrative Staff

Principals, Partners or Officers:

Employees:

Licensing & Risk
20. A principal of our firm is a licensed architect or engineer.
21. Our firm is in private practice:  
22. Our firm's total billings were under $500,000 in our last fiscal year.
23. Our firm had fewer than two claims in the past five years.
24. If yes, the total amount paid or reserved by the carrier was less than $15,000.
25. Our firm employs 12 or fewer people (part-time or full-time).
26. Our firm is willing to use some form of written agreement on all projects.
27. Our firm or any member of the firm has never had a professional liability policy cancelled (except for nonpayment of premium) or been non-renewed by any insurance company.
28. Our firm is NOT a soils, process, chemical, nuclear, marine or mining engineering firm; a product design firm; a home inspection firm; an asbestos abatement contractor; or a machinery/equipment design firm.
29. Less than 10% of our firm's billings (either this year or next) are derived from pollution cleanup, remediation or containment, underground storage tanks, air emission controls, landfills, superfund sites, environmental permitting or industrial piping or processes.
*If ANY of your firm's services are rendered in these areas (either this year or next), please indicate project type(s) and the percentage of your firm's billing for each service.


 

30. Less than 20% of our firm's billings are derived form Design/Build projects where we, or a related entity, accept responsibility for actual construction by in-house personnel or subcontractors.
*If ANY (either this year or next), please indicate the percentage %.
31. Less than 10% of our firm's billings are derived from asbestos related services.
*If ANY (either this year or next), please indicate the percentage %.

This document is a non-binding indication question sheet and is subject to receipt of a fully completed application and supporting documents prior to firm quotations being rendered by the company.  Upon review of these documents, the company reserves the right to change the terms indicated via this questionnaire or decline to render terms for this coverage.