PLAN: AE Application for Professional Liability Insurance

NEW APPLICANT

Answer all questions

Firm's name:
Street address:
Mailing address:
City:	State:		Zip:
Telephone:		Facsimile:
E-mail:		Web Site:

FIRM PROFILE

*1. Date firm was established:

/ /

Type:
Other:

*2. List all pre-existing entities, including acquisitions and mergers, and their dates of existence :

Dates (From)	Dates (To)	Firm Name

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.

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:

Location (address, city, state, zip & contact)	.
	%
	%
	%
	%
Total must equal 100%	%

12. Provide the percentages of your firm's GROSS RECEIPTS that were paid to subconsultants and subcontractors during the last complete year.

Yes No%

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			3. Field services
%	Total of all design Services		%	a. Construction observation without design
.	%	Percentage with construction observation	%	b. Inspection as a stand-alone service
.	%	Percentage without construction observation	%	c. Boundary and construction staking
.	0	.	%	d. Construction materials testing (including compaction testing)
2. Non-design services			%	e. Drilling and sampling (geotechnical)
%	a. Quantity or cost estimates without design		%	f. Laboratory analysis (including soils and construction materials, but not environmental)
%	b. Plan checking without design		%	g. Other (describe)
%	c. Building commissioning (quality assurance process as a separate service)		B. Operation and Management Services (of these facilities)
%	d. Feasibility, programming, planning, economic or seismic studies		%	a. Domestic water, utility, building, other facilities
%	e. Architectural master planning		%	b. Wastewater treatment plants, landfills, chemical processing plants (describe)
%	f. Forensic inspections, expert witness services, failure analysis		%	c. Other (describe)

C. Environmental Services

1. Environmental engineering (detection, determination and remediation of contaminated sites)		2. Environmental sciences
%	a. Preliminary site assessments (PSA-Phase I)	%	a. Permitting
%	b. Other environmental assessments (compliance audits, environmental impact studies)	%	b. Industrial hygiene
%	c. Investigations (drilling and sampling, Phase II)	%	c. Laboratory analysis (chemical and analytical)
%	d. Studies (feasibility, siting, closure, hydrogeological, hydrological)	%	d. Environmental training and manuals for other than internal usage
%	e. Asbestos and lead studies (inspection, identification, work plans)	%	e. Fish and wildlife or botanical studies, including wetland delineation
%	f. Asbestos and lead abatement	%	f. Forensic inspections, expert witness services
%	g. Design services (remediation, environmental facilities, pollution control systems)
%	h. Site remediation activities and remediation observation or management	3. Other environmental services (describe)
%	i. Environmental project observation/oversight (non-remediation)(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.

Estimated current year	Last complete year		Estimated current year	Last complete year
ARCHITECTURE			ENGINEERING
%	%	Architecture	%	%	Structural engineering
%	%	Architectural planning (including master planning)	%	%	Civil engineering
%	%	Interior design and graphics	%	%	Civil wastewater engineering (municipal, non-industrial)
%	%	Landscape architecture	%	%	Land surveying
LABORATORY			%	%	Traffic engineering
%	%	Construction materials testing (non-environmental)	%	%	Mechanical engineering
%	%	Environmental (analytical)	%	%	Acoustical engineering
%	%	Conformity assessment* (product testing and materials science)	%	%	Process engineering
%	%	Life sciences* (clinical research - not diagnostic medical labs)	%	%	Electrical engineering
%	%	Microbiology and analytical chemistry* (food, drugs, personal care products) *Complete Laboratory Questionnaire	%	%	Illumination engineering
ENVIRONMENTAL			%	%	Geotechnical engineering (soil mechanics for structures)
%	%	Environmental engineering (including mines and mining waste treatment) - See question 14C	%	%	Geotechnical field services and construction materials testing (including drilling)
%	%	Environmental science - See question 14C	OTHER
%	%	Industrial wastewater engineering (non-municipal)	%	%	Marine engineering (describe)
%	%	Geo-environmental engineering (including landfills, waste treatment and retention ponds)	%	%	Naval architecture (describe)
%	%	Totals must equal 100%	%	%	Other (describe)

PROJECTS

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

HIGH RISE		INDUSTRIAL
%	All buildings over 15 stories (DO NOT classify these below.)	%	Processing, manufacturing and production systems
%	Do any of these buildings include residential condominiums?	%	Mines, quarries, tunnels
RESIDENTIAL		%	Oil refineries
%	Residential condominiums	%	Chemical plants and pipelines
%	Planned Unit Developments (PUDs)	%	Facilities related to nuclear activities
%	Single-family residential subdivisions	RECREATIONAL FACILITIES
%	Custom homes	%	Sports facilities, arenas, convention facilities, grandstands, theaters, amusement parks (describe your services for each)
%	Apartments	%	Ski lifts, amusement rides (describe your services for each)
INSTITUTIONAL		INFRASTRUCTURE
%	Hospitals, retirement homes, convalescent hospitals	%	Utilities
%	Public schools, colleges and universities	%	Roads and highways
%	Private schools, colleges and universities	%	Airport runways
%	Churches	%	Transportation passenger terminals (describe your services)
%	Correctional institutions	%	Structures for offshore or marine use, harbors, jetties, docks, piers, wharves
GENERAL BUILDING		%	Bridges, trestles
%	Parking garages	%	Dams, reservoirs, levees
%	Hotels	%	Landfills
%	Motels	%	Wastewater, sewage and water treatment systems
%	Retail, malls, shopping centers	%	Waste treatment, storage or disposal facilities
%	Office, warehouse, processing, manufacturing and production buildings	OTHER
%	Restaurants	%	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
%	Total (must equal 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:

Yes No	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

*21. Has your firm completed an organizational peer review through a professional association?
If yes, when and by whom?

Yes No

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)
%	Total must equal 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?
If yes, describe

Yes No

25. Does your firm use a limitation of liability provision in its contracts?
If yes, complete the Limitation of Liability Report for possible premium credit.

Yes No

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?
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 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 Year	/		$	$	$
Last Year	/		$	$	$
Two years ago	/		$	$	$
Three years ago	/		$	$	$
Four years 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
$250000 $500000 $1 Million $2 Million $3 Million $4 Million $5 Million	$250000/500000 $500000/$1 Million $1 Million/$2 Million $2 Million/$4 Million $3 Million/$5 Million	$5000 $10000 $15000 $25000 $50000
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 materialthereto 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:	07/31/2010

What is important to your firm in your selection of a professional liability company?

Agent recommendation
Claims service
Company reputation
Educational programs
Policy coverage
Price
Professional society endorsement
Other: