Insurance For Engineers Maricopa County

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Name of Firm:*

Date Established:*

MM slash DD slash YYYY

Contact Name:*

Street Address*

Address Line 2

City*

State / Province*

ZIP / Postal Code*

Phone*

Fax

Email*

Business Practices:

Does the firm include a written contract on every project*

Yes

If No what % is a contract used*

What percentage of your firm’s contract:*

Include Limitation of Liability %*

Include Limitation of Liability of $250,000 or less %**

Include Limitation of Liability of $250,000 or less %*

Are rendered under AIA or EJCDC %**

Are rendered under AIA or EJCDC %*

Specify payment terms %**

Specify payment terms %*

Do you have continuing education and training programs for professional personnel?*

Yes

Do you have LEED Certification or equivalent?*

Yes

If “Yes”, please indicate approximate % of professional employees certified:*

List professional society memberships:*

Predecessor Firm:

Name*

Dates in Existence*

MM slash DD slash YYYY

Nature of Change*

Contractual Responsibility:

Based on the firm’s Gross Billings, indicate the approximate percentage of contractual responsibility undertaken, based on the following categories. (Note: This section must total 100%)

Design only, with no construction phase responsibility (%)*

Design with Observation of Construction duties (%)*

Observation of Construction only (%)*

Design with Construction responsibility (Construction in-house or subcontracted) (%)*

Construction with Design responsibility (All Design subcontracted) (%)*

Construction Management “Agency” (no direct responsibility for construction) (%)*

Construction Management “At Risk” (direct responsibility for construction) (%)*

Feasibility Studies (%)*

Design Build Projects (%)*

Total 100%*

Services Provided

Specify the services provided by the firm: (Note: This section must 100%)

Architecture (%)*

Traffic Engineering (%)*

Landscape Architecture (%)*

Land Surveying (%)*

Golf Course Architecture (%)*

Mechanical Engineering (%)*

Interior Design (%)*

HVAC Engineering (%)*

Structural Engineering (%)*

Civil Engineering (%)*

Electrical Engineering (%)*

Environmental Engineering (%)*

Process Engineering (%)*

Communication Engineering (%)*

Other (specify) (%)*

Please indicate the services provided*

Total 100%*

Land Surveyors (Please complete)

Did you provide a percentage in Land Surveyor above?*

Yes

Indicate the approximate percentage of billings derived from each of the following categories: (This section must total 100%)

Boundary or property surveys (%)*

Topographic surveys (%)*

Route surveys for engineering projects (%)*

Construction stakeout (%)*

Photogram metric surveys (%)*

Hydrographic surveys (%)*

Geodetic or control surveys (%)*

Quantity surveys (%)*

Mapping or cartography (%)*

Oil/Gas Well location surveys (%)*

Other services requiring engineering stamp (%)*

Subdivision work (Supervision of Plat Plans, Grading and site work, Subdivision roads and streets, curbs, gutters and natural drainage, other subdivision utilities (%)*

Plans and/or specifications for streets or highways, natural drainage systems, utilities, or building and other structures. (%)*

Please describe these exposures in detail here.*

Total 100%*

Billings

Projected Next Calendar Year 20_ _ (In all cases, the applicant must fill out the last two numbers)

Section Break

Last Completed Calendar Year ($)

Second Past Completed Calendar Year ($)

Projected Current Calendar Year ($)

Projected Next Calendar Year ($)

Section Break

Last Completed Calendar Year ($)*

Second Past Completed Calendar Year ($)*

Projected Current Calendar Year ($)*

Projected Next Calendar Year ($)*

Fees from abandoned projects

Fees from abandoned projects of Last Completed Calendar Year*

Fees from abandoned projects of Second Past Completed Calendar Year*

Fees from abandoned projects of Projected Current Calendar Year*

Fees from abandoned projects of Projected Next Calendar Year*

Fees passed through to consultants

Fees passed through to consultants of Last Completed Calendar Year*

Fees passed through to consultants of Second Past Completed Calendar Year*

Fees passed through to consultants of Projected Current Calendar Year*

Fees passed through to consultants of Projected Next Calendar Year*

Direct reimbursable

Direct reimbursable of Last Completed Calendar Year*

Direct reimbursable of Second Past Completed Calendar Year*

Direct reimbursable of Projected Current Calendar Year*

Direct reimbursable of Projected Next Calendar Year*

All other professional services

All other professional services of Last Completed Calendar Year*

All other professional services of Second Past Completed Calendar Year*

All other professional services of Projected Current Calendar Year*

All other professional services of Projected Next Calendar Year*

ANNUAL TOTAL REVENUES

ANNUAL TOTAL REVENUES of Last Completed Calendar Year*

ANNUAL TOTAL REVENUES of Second Past Completed Calendar Year*

ANNUAL TOTAL REVENUES of Projected Current Calendar Year*

ANNUAL TOTAL REVENUES of Projected Next Calendar Year*

Type of Sub consultants used*

% of Sub consultants insured*

Airports (%)*

Environmental Impact Statements (%)*

Religious (%)*

Apartments (%)*

Highways/Roads (%)*

Sewer/Water Lines (%)*

Bridges less than 500 feet (%)*

Hospitals (%)*

Shopping Centers (%)*

Bridges over 500 feet (%)*

Hotels / Motels (%)*

Condominiums (%)*

Industrial (%)*

Subdivisions/Tract Housing (%)*

Convention Centers (%)*

Marine / Naval (%)*

Subsidized Housing (%)*

Mass Transit Lines (%)*

Correctional Facilities (%)*

Custom Homes (%)*

Tunnels (%)*

Municipal Water Systems (%)*

Warehouses (%)*

Dams (%)*

Office Buildings (%)*

Wastewater Treatment (%)*

Educational (%)*

Parking Garages (%)*

Other (specify): (%)*

Total 100%*

Indicate the percentage of services provided to the following clients: (Total must NOT equal 100%):

Contractor (%)*

Developer (%)*

Governmental (%)*

Lending Institution (%)*

Design Professionals (%)*

Firm History

In the past year, have any of the following changes taken place:

A name change?*

Yes

Merger with or acquisition of another firm?*

Yes

Any new joint venture project?*

Yes

Any new projects with direct construction responsibility, such as design/build or construction management?*

Yes

Any new foreign projects:*

Yes

Prior Coverage

If you have a professional liability policy in force, please provide:

Name of Insurer:*

Limits of Liability:*

Effective date:*

MM slash DD slash YYYY

Retro active date:*

MM slash DD slash YYYY

Premium*

First dollar defense?*

Yes

Is the firm covered by any professional liability specific project policy?*

Yes

The name of the project:*

Address of the project:*

Name of the insurance company providing the policy:*

Terms of the policy:*

Claims*

Have any claims been made or legal action been brought in the past five years against your firm, its predecessors or any past principal, Partner, officer, director, shareholder or employee?

Yes

If yes, please provide loss runs for the pasts five years.*

Max. file size: 128 MB.

Important Note:

When renewing a claims-made policy, it is very important that potential claims and circumstances be identified and reported under the expiring policy. Failure to properly report circumstances that are known to your firm could jeopardize your coverage should a claim arise in the future. Any actual claims should be reported promptly at all times.

Situations that may indicate the possibility of a future claim include the following:

• A threat of a claim, whether written or oral.
• A demand for money or services.
• A request to appear at mediation, arbitration or other dispute resolution hearing.
• A request from a client, a client’s attorney or an insurer for a copy of a client’s file.
• A subpoena for records.
• A notice to appear at a deposition or other hearing under oath.
• A complaint against your firm filed with a professional regulatory board or government agency.
• An investigation by a governmental agency that includes your firm, whether or not your firm is the primary target of the investigation.
• An angry client who directly expresses dissatisfaction with your services.
• An outstanding suit for fees or a client who refuses to pay for your services.
• Construction cost overruns or project delays that a client or contractor may be blaming on your firm.
• A death or serious injury on a jobsite.

Should you be aware of any of these circumstances, or any other circumstances that you believe might result in a claim in the future, you should immediately report the details to your current professional liability insurer.

After careful consideration, the undersigned agrees that there are no claims or possible claims or circumstances that might result in a claim that have not been properly reported to a professional liability insurer. All such claims, possible claims and circumstances have been identified as part of this application for insurance.

Signature*

Name*

Title*

Name of Applicant Firm*

Date*

MM slash DD slash YYYY

Insurance for Engineers & Architects – Information

Insurance for Engineers & Architects – Information

Business Practices:

Predecessor Firm:

Contractual Responsibility:

Services Provided

Land Surveyors (Please complete)

Billings

Section Break

Section Break

Fees from abandoned projects

Fees passed through to consultants

Direct reimbursable

All other professional services

ANNUAL TOTAL REVENUES

Firm History

Prior Coverage

Important Note:

Situations that may indicate the possibility of a future claim include the following:

Should you be aware of any of these circumstances, or any other circumstances that you believe might result in a claim in the future, you should immediately report the details to your current professional liability insurer.