CONTRACTOR’S PROTECTIVE,
PROFESSIONAL AND POLLUTION LIABILITY INSURANCE
APPLICATION FORM
Coverage Desired: Protective Liability
Professional Liability
Pollution Liability
Limits of Liability Requested: __________ / _________ Deductible: ____________ / ____________________ / _________ ____________ / __________ __________ / _________ ____________ / __________
1. a) Name of Insured and all subsidiary companies to be insured under this Policy:
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ b) Insured Address: ______________________________________________________________ c) Web site: ______________________________________________________________ d) Contact name: ______________________________________________________________ e) Contact phone: ___________________ Fax: _______________________________
2. a) Description of Contracting Operations and/or Professional Services:
______________________________________________________________________________ b) Number of Staff:
Principals
Licensed Architects Licensed Engineers Construction Managers Superintendents
Other Technical Consultants Total Staff:
c) Please provide a geographical breakdown (by percentage) of your business in the U.S.:
d) Do you do any work outside the U.S.:
Yes
NoIf Yes please explain
______________________________________________________________________________ 3. a) Revenue Data
Service Performed
Past 12 Months Construction Values
Past 12 Months Professional Fees Upcoming 12 Months Construction Values Upcoming 12 Months Professional Fees General Construction Only (No
Design or CM responsibilities Construction Management At- Risk
Construction Management Agency
Design/Build w/ in-house Design
Design/Build w/ sub-contracted Design
In-House Design Only Services for Third Parties
Development, Property Management, Real Estate Agent, or Leasing Agent Fees Other Technical or
Professional Service Fees (please explain)
Totals:
b) Have there been any changes to the scope of services rendered by your
Firm in the past three years?
Yes
NoIf yes please describe:
______________________________________________________________________________ State % of
Work State
% of
Work State
% of
Work State
% of
Work State
% of Work
AL HI MI NC SC
AK ID MN ND SD
AZ IL MS OH TN
AR IN MO OK TX
CA IA MT OR UT
CO KS NE PA VT
CT KY NV RI VA
DE LA NH SC WA
DC ME NJ SD WV
FL MD NM TN WI
4. Project Types Percentage of your Firm’s Revenues attributable to the following project types (must total 100%):
Project Type % Project Type %
Airports Nuclear/Atomic
Apartments Office Buildings
Bridges Parking Structures
Churches Petro/Chemical
Condominiums Power Plants
Convention Centers Recreational
Dams Roads/Highways
Environmental/Remediation Schools/Colleges Harbors/Piers/Ports Shopping Center/Retail
Hospitals Stadiums
Hotels/Motels Telecomm
House: Custom Tunnels
House: Multi-Unit Townhouse Utilities
Interior Fit-Out/ Renovation Wastewater Treatment Plants
Jails Water Systems
Landfills Libraries
Manufacturing/Industrial Mass Transit
Mines
5. Contracting Procedures:
a) What percentage of your work is from repeat clients? % Largest client? % b) What percentage of your work is negotiated? % Hard bid? % c) Does your firm have a financial/equity interest in any projects?
Yes
No If Yes, please identify and describe:______________________________________________________________________________ d) Percentage of your firm’s revenue attributable to the following client types for the last complete year:
Private Developers % Commercial % General Contractors %
Federal Government % State Government % Local Government %
e) List your most recent year’s number of projects by size:
Construction Value Number of Projects
Up to - USD10,000,000
USD10,000,000 - USD25,000,000
USD25,000,000 - USD100,000,000 More than USD100,000,000
Total
f) What percentage of your firms professional services or operations are performed under
written contracts? ______________________________________________________________ % g) What percentage of your firm’s contracts are:
AIA _____% AGC _____% DBIA _____% EJCDC _____%
Client Drafted Agreements _____% Purchase Orders _____%
Firm’s Standard Agreement _____% Master Service Agreements _____% h) Who reviews and negotiates client and/or subcontract agreements?
______________________________________________________________________________ i) Who has the authority to review and/or approve non-standard contract agreements?
______________________________________________________________________________ j) Are Formal Change Order Provisions utilized?
Yes
No k) Does Your Firm use Limitation of Liability provisions in contracts?
Yes
NoIf Yes, please include a copy of the provision
l) Do you follow written in-house quality control procedures?
Yes
No m) Do you have an in-house program of continuing education forprofessional staff?
Yes
Non) Do any projects employ any Leadership in Environmental Engineering Design (LEED) or any “Green Building” technologies/materials, energy efficiency use or certification?
Yes
No If Yes, please explain:______________________________________________________________________________ o) Do any projects employ a Building Information Modeling (BIM) or
similar system?
Yes
No If Yes, explain control systems in place to safeguard security, coordination, and control of design?6. Design Services
a) Are you ever responsible for subcontracting design services?
Yes
No b) What limit of Professional Liability insurance do you require fromsubcontracted design professionals? USD __________________
c) Do you obtain Certificates of Insurance from subcontracted design professionals?
Yes
No d) Do you provide Value Engineering, Cost Reduction and/orConstructability Review Services?
Yes
No 7. Insurance Information:a) Please identify your Firm’s current General Liability Insurance Coverage:
Company Limit Deductible Policy Period
Does your current coverage have any of the following endorsements:
CG2243
CG2279
CG2280
b) Does your firm currently purchase Professional Liability Insurance?
Yes
No If Yes, please provide coverage information for the past 3 years:Company Limit Deductible Policy Period
Retroactive Date: ______________________________________________________________ c) Does your firm currently purchase Contractors Pollution Liability Insurance?
Yes
NoIf Yes, please provide coverage information for the past 3 years:
Company Limit Deductible Policy Period
8. Pollution, Mold, and Fungus Supplemental
a) Do you currently purchase mold and fungus coverage?
Yes
No If Yes, please complete information below:Limit Deductible Retroactive Date
b) Have you previously had any mold incidents/claims?
Yes
No If Yes please describe:______________________________________________________________________________ c) Does your firm have formal written mold protocols for the prevention/remediation
of water intrusion/mold?
Yes
No If Yes, please attach a copy.When were the protocols implemented? _____________________________________________ Since the protocols were implemented, have there been any problems?
Yes
No d) Do any projects have any known “environmental” problems, concerns or restraints.Environmental includes but is not limited to: projects built on “Greenfield” or “Brownfield” sites, projects with wet lands restrictions, property previously used for any industrial purpose, projects with known asbestos fibers or materials in need of abatement, encapsulation or removal, any noted underground stored tanks?
Yes
No If Yes, please describe:______________________________________________________________________________ 9. Claims Information:
a) Has any claim, suit, notice, or legal action been made or brought (or made earlier and still pending) against your company, its predecessors, or any past or present Principal, Partner, Officer or Director or other prospective insured party of your company?
Yes
No If yes, please provide the following details:- Date of Claim - Allegations
- Insurance Company Reserve
- If closed, total loss payment (indemnity payment plus defense costs) - Defense attorney or insurance company’s evaluation of claim
b) Are you aware of any other circumstances or incidents which may result in a claim being filed against your company?
Yes
No If Yes, please provide details.c) Has any claim ever been filed by you against a design professional?
Yes
No If Yes, please provide details.______________________________________________________________________________ d) Do you know of any circumstance, project problem or delay that could reasonably be expected to result in
a claim?
Yes
No If Yes, please provide details.______________________________________________________________________________
The applicant has read the foregoing and understands that completion of this Application does not bind the Underwriter or the Broker to provide coverage. It is agreed, however, that this Application is complete and correct to the best of applicant’s knowledge and belief and that all particulars which may have a bearing upon acceptability as a Professional Liability Insurance risk have been revealed. It is understood that this Application shall form the basis of the contract should the Underwriter approve coverage and should the applicant be satisfied with the Underwriter’s quotation.
Declaration
I declare that the statements and particulars in this application are true and that no material facts have been misstated or suppressed after enquiry. I agree that this application, together with any other information supplied shall form the basis of any contract of insurance effected thereon. I undertake to inform the Insurers of any material alteration to those facts occurring before completion of the contract of insurance. A material fact is one which would influence the acceptance or assessment of the risk.
Signed: ...
Title: ... (to be signed by Authorized Representative of Insured)
Print Name: ...
