PLAN: AE Application for Professional Liability Insurance

Firms with fees of $500,000 or less with the following disciplines may qualify for the Small Firm Program:

Architecture; Architectural Planning; Interior Design; Landscape Architecture; Land Surveying; Civil (Waste Water & All Other), Structural, Mechanical, Electrical, Acoustical, Illumination, Process and Traffic Engineering.

If your firm meets the following requirements and can answer "No" to all of the following questions, you may be eligible for DPIC’s Small Firm Program.

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 bankruptcy.
The principals and professionals of your firm agree to complete the DPIC Professional Liability Education Program "Liability IQ" within three years.
Your firm's gross receipts for the last five complete fiscal years and projected fiscal year are $500,000 or less.

Qualification Checklist (for firms with gross receipts up to $500,000)
In the past three years, and for your projected work for next year, did your firm:

1.	Engage in design-build, construction, manufacturing, fabricating, real estate development or project financing or have financial interest in organizations that do?	Yes No
2.	Conduct work related to :	.
.	a. pollution	Yes No
.	b. asbestos	Yes No
.	c. environmental projects that involve PSAs, remediation or retaining subconsultants and/or subcontractors?	Yes No
3.	Perform construction management services? (This does not include construction phase services on projects you designed.)	Yes No
4.*	Contract with more than 10% uninsured design professional subconsultants?	Yes No
5.*	Enter into more than 10% of projects without written contracts?	Yes No
6.	Have more than one professional liability claim?	Yes No
7-I.	Perform services on :	.
.	a. Ski lifts, amusement rides?	Yes No
.	b. Residential condominium projects, planned unit developments or time-share projects?	Yes No
.	c. Any project involving design of any building, system or component intended to be manufactured or used on more than one project without site adaptation?	Yes No
7-II.
.	a. Sport facilities, arenas, convention facilities, grandstands, theaters, amusement parks, transportation passenger terminals (excluding interior and landscape design services)?	Yes No
.	b. Mines, quarries, tunnels, bridges or trestles?	Yes No
.	c. Structures for offshore or marine use, harbors, jetties, docks, piers, wharves?	Yes No

* Question 4 and 5 do not apply to firms without retroactive coverage. If the firm does not have retroactive coverage, please check "No."

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

Name of Principal,Partner, or Officer:
Title:		Date of application:	07/31/2010