Euclid Insurance

Architects and Engineers Professional Liability Application

Important Notice - this application is for a claims-made insurance policy. Claim expenses will reduce the limit of liability. The deductible applies to both damages and claim expenses.

Name of Applicant / Firm:
Principal Business Address:
City:
County:
State:
ZIP Code:
Business Phone:
Fax:
Internet address:
Please list all branch offices on a separate sheet and include a breakdown of the staff at each location.

Applicant’s practice is:	Full-time (more than 30 hours/week) Part-time
Date current firm was established:
If part-time, specify other employment:

List all pre-existing entities, including name changes, acquisitions and mergers, date of existence and nature of the change. Attach additional details if necessary. Firms that are accepted for coverage will be listed on the policy.

Name of Predecessor Firm:
Dates in Existence:
Nature of Change:

Total Staff (include branch offices): Indicate part-time by ½

	Officers, partners, owners	Employees
Licensed Architects
Licensed Engineers
Technical Staff
Administrative Staff

List professional society memberships (ctrl+click for multiple selection):
Other (please specify):

What percentage of professional employees have participated in continuing education programs within the last two years?

Does the firm currently carry professional liability insurance?	Yes No
If “yes”, provide details of insurance history:
Insurance Company:
Policy Period:
Limit of Liability:
Deductible:
Premium:
Retroactive date on current policy:

Is the firm covered by any professional liability specific project policy?	Yes No
If "yes" provide the name and address of project name of insurance company and term of policy:

Does the firm carry general liability insurance?

Yes
No

10.

Specify the services provided by the firm: (Note: Total must equal 100%)

Architecture	%
Civil Engineering	%
Communication Engineering	%
Electrical Engineering	%
Environmental Engineering	%
Golf Course Architecture	%
HVAC Engineering	%
Interior Design	%
Land Surveying	%
Landscape Architecture	%
Mechanical Engineering	%
Process Engineering	%
Structural Engineering	%
Traffic Engineering	%

11.

If the firm’s practice includes fees passed through to consultants for architectural, engineering or surveying services:

Specify the types of services provided by consultants:
Percentage of consultants that carry professional liability insurance:	%
Consultant’s fees should be specified in question 12.d.

12.

Specify annual revenues:

	Second Past Fiscal Year From (mo/yr) To	Last Complete Fiscal Year From (mo/yr) To	Projection for Current Year From (mo/yr) To
a. Projects insured separately
b. Joint Venture projects
c. Fees from abandoned projects
d. Fees passed through to consultants
e. Direct Reimbursables
f. All other professional services
g. ANNUAL TOTAL REVENUES

13.

Indicate the services provided by the firm: (Note: must total 100%):

a	Feasibility studies	%
b	Design only, no construction phase services	%
c	Design with observation of construction	%
d	Design with construction management services*	%
e	Construction management without design*	%
f	Complete responsibility for construction, including design**	%
g	Other (specify):	%

*Complete the Construction Management Information Sheet.
**Complete the Design/Build Information Sheet.

14.

Indicate the types of projects undertaken (Note: must total 100%):

Airports		%
Apartments		%
Bridges greater than 500 feet		%
Bridges less than 500 feet		%
Condominiums		%
Convention Centers		%
Correctional Facilities		%
Custom Homes		%
Dams		%
Educational		%
Environmental Impact		%
Highways/Roads		%
Hospitals		%
Hotels/Motels		%
Industrial		%
Marine/Naval		%
Mass Transit Lines		%
Municipal Water Systems		%
Office Buildings		%
Parking Garages		%
Religious		%
Sewer/Water Lines		%
Shopping Centers		%
Site Development		%
Subdivisions/Tract Housing		%
Subsidized Housing		%
Tunnels		%
Warehouses		%
Wastewater Treatment		%
Other (Specify)		%

15.

Indicate the types of clients (Note: must total 100%):

Commercial		%
Contractors		%
Design Professionals		%
Developers		%
Governmental		%
Industrial		%
Institutional		%
Lending Institutions		%
Owners who act as builders		%
Other (specify):		%

16.

What percentage of annual billings come from your largest single client? %

17.

Has the firm participated in any of the following projects or services in the last 10 years?

	Amusement Rides or Water Slides
	Asbestos Testing or Abatement
	Hazardous or Toxic Waste
	Laboratory Testing or Analysis
	Landfills
	Machinery, Equipment or Product Design
	Mines
	Nuclear or Atomic
	Phase I, II or III Site Assessments
	Projects constructed outside the U.S.A.
	Refinery or Chemical
	Runways or Taxiways
	Soils Engineering
	Stadiums or Arenas
	Superfund

Please provide details of the project(s), including project named, location, client, billings, constructions values and completion date.

18.

Does the firm or any enterprise financially related to the firm or its principals, partners, directors or officers engage in any of the following:

Construction, erection, fabrication or installation
Yes
No
Manufacture, sale or distribution of any product or process
Yes
No
Real estate development
Yes
No

If “yes”, provide full details.

19.

Has the firm ever provided any professional services on projects for which the firm or a related person or enterprise has acted as a general contractor by providing or subletting construction?

Yes
No

If “yes”, provide full details or complete the Design/Build Information Sheet.

20.

a. Does the firm wholly or partly own, manage or control any other enterprise?
Yes
No

If “yes”, provide full details.

b. Is the firm wholly or partly owned, managed, or controlled by any other enterprise?
Yes
No

If “yes”, provide full details.

21.

Does the firm provide professional services for any client in which any member of the firm or their relatives own a financial interest or serves as an officer, director, trustee or partner?
Yes
No

If “yes”, provide the name of the client, project, percentage of equity interest, nature of relationship, gross billings for the last year and type of services.

22.

Has the firm participated in a Joint Venture in the last five years?
Yes
No

If “yes”, please attach a Joint Venture Information Sheet or statement providing full details for each joint venture project.

23.

a. Does the firm use written contracts on every project?
Yes
No

b. If “no”, please indicate the percentage of projects during the last 12 months that used verbal contracts: %
Describe circumstances under which verbal agreements are used:

c. What percentage of professional services are rendered under AIA or EJCDC standard forms of agreement?
%

d. When non-standard contracts including “letter agreements” and modified AIA or EJCDC contacts are used, are they reviewed by the firm’s legal counsel prior to signing?
Yes
No

24.

a. Has the firm adopted a policy against suing for fees?
Yes
No

b. Please indicate the number of suits filed for the collection of fees during the last two years:

25.

Have any claims involving professional services been made against the firm or any predecessor firm in the last ten years?
Yes
No

If “yes”, complete a Claim/Circumstance Information Sheet or attach full details, including actions taken to prevent similar claims in the future.

26.

Has the firm or any predecessor firm reported a potential claims to a professional liability insurer in the last five years?
Yes
No

If “yes”, complete a Claim/Circumstance Information Sheet or attach full details.

27.

After inquiry, is any member of the firm or a predecessor firm aware of any circumstance that could possibly result in a professional liability claim being made against them?
Yes
No

If “yes”, complete a Claim/Circumstance Information Sheet or attach full details.

28.

Has any member of the firm ever been the subject of a complaint to authorities or disciplinary action as a result of the professional activities?
Yes
No

If “yes”, please attach a statement providing full details.

29.

Attach a list of the firm’s five largest completed projects. Include the project name, client, location, services rendered, billings, construction values and completion date.

30.

Attach a list of the firm’s five largest current projects, including the details requested in question 29.

31.

Please attach any literature, including government forms, brochures or descriptive information which is sent to new or prospective clients, that describes the firm’s capabilities and practice.

WARNING

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, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. IN SOME JURISDICTIONS, INSURANCE FRAUD MAY ALSO BE SUBJECT TO CRIMINAL AND/OR (NY: SUBSTANTIAL) CIVIL PENALTIES. IN MAINE AND VIRGINIA, INSURANCE BENEFITS MAY ALSO BE DENIED.

BY SIGNING THIS APPLICATION I HEREBY AUTHORIZE THE INSURANCE COMPANY TO USE THE INFORMATION CONTAINED IN THIS APPLICATION AND IN THEIR FILES FOR THE PURPOSE OF UNDERWRITING THIS INSURANCE. THE APPLICATION MUST BE SIGNED BY AN OWNER, PARTNER OR PRINCIPAL.

Signed (Please print name.):

Date:

Title :

Licensed Insurance Agent

SIGNING THIS APPLICATION OR INCLUDING PREMIUM WITH ITS SUBMISSION DOES NOT BIND THE APPLICANT OR THE COMPANY TO COMPLETE THE INSURANCE.

Application must be signed and dated to be considered for quotation. A properly completed, signed and dated, original application will allow for prompt issuance of coverage should quotation be offered and accepted.

Submitting this form does not bind the insurance company or agency to sell nor the applicant to purchase the insurance.

Euclid Insurance I 234 Spring Lake Drive I Itasca, IL 60143 I Phone: 630-694-3700 (ask for a member of the A/E Team) I Fax: 630-773-4075 I E-Mail: ae@euclidinsurance.com
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