Insurance Application | Apply for Professional Liability & Business Coverage

1 General Information

Firm Name *

Federal Tax ID (FEIN) *

Street Address *

City *

State *

Zip *

Insurance Contact *

Title *

Phone *

Email *

Fax

Website

Date Operations Commenced *

Firm Structure: *

Pre-existing Entities (including acquisitions and mergers):No pre-existing entities other than listed above

Entity Name	From	To	Relationship

Number of Staff: *

Licensed Principals

Non-licensed Principals

Other Licensed Staff

Technical

Admin

Total

Has the applicant or any subsidiary in the past 3 years been involved with, or contemplated in the next 12 months, any merger, acquisition, or divestment?

Yes No

How did you hear about our program?

2 Gross Billings

Firm's gross annual billings for the past three years. *

Projected

Last Year*

2 Years Ago

3 Years Ago

a. Fiscal year end date

b. Gross billings ($)

c. Subconsultants ($)

d. Direct reimbursable expenses ($)

e. Net billings ($)

f. % Subconsultants (c ÷ b)

N/A

g. Feasibility studies ($)

h. Projects permanently abandoned ($)

i. Projects insured under separate project policies ($)

j. Joint venture projects — your portion ($)

*Last full fiscal year

3 Disciplines% of Last 12 Completed Months' net billings — must total 100% *0% of 100%

4 Servicesmust total 100% *0% of 100%

International Work — If yes, describe:

Yes No

% of billings from international work

%

5 Project Types% of Last 12 Completed Months' net billings — must total 100% *0% of 100%

6 Clients & Owners

Type of Owner: (must total 100%) 0%

Federal	State & Local Gov't	Institutional	Private	Other (describe)	Total
%	%	%	%	%

Federal

State & Local Gov't

Institutional

Private

Other (describe)

Total

%

Type of Client: (must total 100%) 0%

Contractors	Developers	Owners	Design Firms	Other (describe)	Total
%	%	%	%	%

Contractors

Developers

Owners

Design Firms

Other (describe)

Total

%

7 Subconsultants

What percentage of Last Year's Gross Billings was paid to subconsultants? (Total should match % from Section 2, line f)

Subconsultant Type	Insured for PL (%)	NOT Insured for PL (%)
SUBTOTAL	0%	0%

Other subconsultant description:

8 Contracts & Risk Management

8a. Contract usage as a % of gross receipts (must total 100%) 0%

Prof. Assoc. (AIA/ACEC/ASFE)	Firm's Standard	Letter Agreement	Purchase Order	Client Agreement	Oral Agreement	Total
%	%	%	%	%	%

Prof. Assoc. (AIA/ACEC/ASFE)

Firm's Standard

Letter Agreement

Purchase Order

Client Agreement

Oral Agreement

Total

%

If Yes to items r through x, provide details in Section 11 (Additional Information).

What percentage of the Applicant's annual billings was derived from projects utilizing Building Information Modeling (BIM) or Virtual Design and Construction (VDC)?	%
What percentage of the Applicant's annual billings was attributable to the design of projects that meet the United States Green Building Council's LEED certification standards?	%

9 Current Insurance Information

Insurance Company

Per Claim Limit

Aggregate Limit

Deductible

Annual Premium

Expiration Date

Retroactive Date

Last Yr

2 Yrs

3 Yrs

4 Yrs

5 Yrs

Does your current policy provide first dollar defense?	Yes No
Do you have a Specific Additional Project Limit Endorsement on your current policy? ? A SAPL Endorsement provides additional limits for a specific project above your base policy limits.	Yes No
Is your firm a named insured under a project policy?	Yes No

If yes to project policy, provide a copy of the declarations page.

Current General Liability Insurance Carrier

Expiration Date

10 Claims & Loss History

Important: Report all claims AND circumstances that may give rise to a claim. This policy will NOT cover claims or situations you are aware of prior to the effective date.

If Yes to any of the above, complete a Claim Reporting Form for each claim:

Claim #1

Description of Claim

Full Name of Claimant(s)

Date of Alleged Act

Date Claim Made

Insurance Company Notified

Present Status

Open Closed

Total Damages Paid / Outstanding ($)

Defense Expenses ($)

Max Amount Demanded ($)

Likely Settlement Value ($)

Actions Taken to Avoid Similar Future Claims

Claim #2

Description of Claim

Full Name of Claimant(s)

Date of Alleged Act

Date Claim Made

Insurance Company Notified

Present Status

Open Closed

Total Damages Paid / Outstanding ($)

Defense Expenses ($)

Max Amount Demanded ($)

Likely Settlement Value ($)

Actions Taken to Avoid Similar Future Claims

* Attach additional Claim Reporting Forms if needed.

11 Additional Information

Use this space for additional details on any question above. Reference the question number.

✦ Declaration & Authorization

The undersigned, acting on behalf of all Applicants, represents that the statements set forth in this Application are true and correct and that thorough efforts were made to obtain requested information from each and every Applicant proposed for this insurance.

Any policy issued will be in reliance upon the truthfulness of the information provided in this Application. The signing of this Application does not bind the undersigned to purchase insurance.

FRAUD NOTICES — STATE SPECIFIC DISCLOSURES

ALABAMA	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 is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
ARIZONA & MISSOURI	Claim Expenses are Inside the Policy Limits. All claim expenses shall first be subtracted from the limit of liability, with the remainder, if any, being the amount available to pay for damages.
ARKANSAS, LOUISIANA & WEST VIRGINIA	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.
DISTRICT OF COLUMBIA	Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines.
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.
HAWAII	For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
IDAHO & OKLAHOMA	Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
KANSAS	Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison.
KENTUCKY	Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, commits a fraudulent insurance act, which is a crime.
MAINE, TENNESSEE, VIRGINIA & 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.
MARYLAND	Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in an application for insurance is guilty of a crime.
MICHIGAN	Any person who knowingly and with intent to defraud an insurance company files an application for insurance containing any materially false information commits a fraudulent act, which is a crime.
NEW JERSEY	Any person who knowingly includes any false or misleading information on an application for an insurance policy or files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
NEW HAMPSHIRE	It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding the company.
NEW MEXICO & RHODE ISLAND	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 civil fines and criminal penalties.
OHIO	Any person who, with intent to defraud or knowing that he 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.
OREGON	Any person who knowingly and with intent to defraud or solicit another to defraud any insurance company by submitting an application containing a false statement as to any material fact, may be violating state law.
PENNSYLVANIA	Any person who knowingly and with intent to defraud any insurance company files an application for insurance containing any materially false information commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
VERMONT	Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.
ALL OTHER STATES	Any person who knowingly and with intent to defraud any insurance company files an application for insurance containing any materially false information commits a fraudulent insurance act, which is a crime and may also be subject to civil penalty.

Authorization & Signature

Applicant Name (print) *

Title *

Date *

Authorized Signature *

By signing above, the authorized representative certifies that all statements in this application are true and correct to the best of their knowledge. Completion of this application does not bind the underwriter to provide coverage.

Electronic Signature and Acceptance — Authorized Representative. By checking this box, I agree that my electronic acceptance constitutes my signature with the same force and effect as a handwritten signature. *

a.	Have any claims, proceedings or suits been made or threatened against the applicant in the past 5 years? *	Yes No
b.	Have any claims been made or threatened in the past 10 years? (firms with > $5M billings)	Yes No
c.	Is the applicant aware of any negligent act, error, or circumstance that may reasonably give rise to a claim? *	Yes No
d.	Does the applicant have any pending disputes concerning payment of fees?	Yes No
e.	Has the applicant testified or given a deposition in any dispute where a claim was filed against any party to work you were involved in?	Yes No