CLAIMS-MADE APPLICATION
THE INFORMATION BEING REQUESTED IS FOR A SURPLUS LINES PRODUCT. THE AGENT/BROKER MUST HAVE A SURPLUS LINES LICENSE ISSUED BY THE STATE OF DOMICILE FOR THIS RISK IN ORDER TO RECEIVE A QUOTATION.
THIS APPLICATION IS FOR PROFESSIONAL LIABILITY COVERAGE, WHICH PROVIDES CLAIMS-MADE COVERAGE FOR COVERAGE A - CONTRACTORS PROFESSIONAL LIABILITY. FOR SUCH COVERAGE, DEFENSE EXPENSES ARE PAYABLE WITHIN, AND ARE NOT IN ADDITION TO, THE LIMITS OF INSURANCE. IF COVERAGE B - CONTRACTORS INDEMNITY FOR DESIGN PROFESSIONAL'S LIABILITY IS INCLUDED, SUCH INSURANCE PROVIDES CLAIMS-MADE AND REPORTED COVERAGE, AND ATTORNEY'S FEES AND RELATED EXPENSES ARE NOT PAYABLE UNDER SUCH COVERAGE.
IT IS IMPORTANT THAT YOU READ ALL OF THE PROVISIONS OF YOUR POLICY CAREFULLY.
Answer each question on behalf of all entities seeking insurance coverage, unless specifically requested otherwise.
An Additional Information section is provided at the end of this document for any information that exceeds the space provided.
GENERAL INFORMATION
Proposed First Named Insured & Other Named Insured(s): / Today's Date:Mailing Address:
Telephone Number: / Web Address:
Type of Legal Entity:
Proposed Effective Date (mm/dd/yyyy) / Proposed Expiration Date (mm/dd/yyyy) / Date Business Started:
Agent/Broker Name / Contact Person / Telephone Number:
Agent Address / Email Address / Applicant Home State: / Surplus Lines License #:
REQUIRED ATTACHMENTS
Include the following with the submission:
Statement of qualifications package, include resumes of key professional personnel.
Currently valued past five years professional liability loss history.
Subcontracted form(s) utilized (representative of most subcontracted work and expected to be used on subcontractors performing professional service(s)).
Work in Progress list.
Representative contract forms, if applicable.
COVERAGE INFORMATION
1. / Coverage Request:Limits / Effective Date / Retroactive Date / Deductible - Coverage A / SIR - Coverage B
Coverage A:
Coverage B:
2. / Alternative Coverage Request:
Limits / Deductible - Coverage A / SIR - Coverage B
GEOGRAPHIC AREA OF OPERATIONS
3. Domestic: / % / List key states:4. Canada: / % / List provinces:
5. Foreign: / % / List countries:
OPERATIONS INFORMATION
6. / Complete description of operations, scope of work:7. / Year each proposed named insured was established:
8. / Describe any mergers, public acquisitions, consolidations or divestitures since each proposed Named Insured:
9. / Describe any discontinued operations, including joint ventures:
ACCOUNTING YEAR DATA INFORMATION
10. /Dates of Reporting Period: /
Estimate for Next 12 Months
/ Actual for Past 12 MonthsEstimated Construction Revenues for Reporting Period / Estimated
Professional
Fees / Actual Construction Revenues for Reporting Period / Actual Professional
Fees
A / Insured Designs with Construction Responsibility
B / Insured Subcontracts Design with Construction Responsibility
C / Insured Designs without Construction Responsibility
D / Construction Only – No Design
E / Construction Mgmt. – Agency
Construction Mgmt. – At Risk
F / Wrap Up Projects with Specific Project Professional Policies
G / Wrap Up Projects without Specific Project Professional Policies
H / Other Professional Services
TOTAL
11. Have you been involved in any Residential Wrap-Ups projects in the past five years? Yes No
If yes, please explain:12. List your most recent year’s number of projects, by size:
Construction Value / Number of ProjectsUp to $10,000,000
$10,000,000-25,000,000
25,000,000-100,000,000
More than 100,000,000
Total
DISCIPLINES OF SERVICE OR OPERATIONS INFORMATION
13. Please break down the total revenue show in #10 above by the professional services or operations shown below.
Types of Services or Operations / % Direct / % Subcontracted /Professional Services
Architecture / % / %
Chemical Engineering / % / %
Civil Engineering / % / %
Construction Management - Agency / % / %
Construction Management - At Risk / % / %
Electrical Engineering / % / %
Environmental Engineering / % / %
Geotech/Soil Engineering / % / %
HVAC Engineering / % / %
Interior Design / % / %
Laboratory Testing / % / %
Land Surveying / % / %
Management Consulting / % / %
Mechanical Engineering / % / %
Mining Engineering / % / %
Naval/Marine Engineering / % / %
Process Engineering / % / %
Structural Engineering / % / %
Traffic Engineering / % / %
Other (explain) / % / %
Contracting
Carpentry / % / %
Demolition/Dismantling / % / %
Drilling / % / %
Electrical / % / %
Excavation Grading/Site Prep / % / %
General Contracting / % / %
Heavy Highway/Bridge / % / %
HVAC / % / %
Mechanical / % / %
Industrial Cleaners (incl. Sewer/Septic) / % / %
Insulation / % / %
Masonry/Concrete / % / %
Marine / % / %
Oil Lease / % / %
Painting / % / %
Pile Driving / % / %
Pipeline Construction/Cleaners / % / %
Plumbing / % / %
Roofing / % / %
Steel Erection / % / %
Street and Road Construction / % / %
Tunnel / % / %
Other (explain) / % / %
Specialty Services
Foundation, Sheeting or Shoring Design / $ / %
Inspections of Commercial Properties / $ / %
Security Design Consulting / $ / %
Plant Monitoring / $ / %
TOTAL / $ / 100 / %
ALLOCATION OF GROSS REVENUES INFORMATION
14. Give the percentage of gross revenue of work held under contract, subcontracts, or as duties to fulfill scope of work for which you hold direct or supervisory responsibility:
a. Acts as a general contractor / %b. Acts as an at risk construction manager / %
c. Acts as an agency construction manager / %
d. Acts as a subcontractor / %
e. Design or consulting services (for work other than environmental/pollution remediation) / %
f. Design or consulting services for environmental/pollution remediation / %
STAFF INFORMATION
15. / Total Construction Personnel /Licensed Engineers or Architects
/ Registered Surveyors / Project Managers / Supervisors or Foremen / OtherCLIENTS/PROJECTS/SERVICES DATA INFORMATION
16. Is your company or any subsidiary, predecessor, or other organization related to your company engaged in:
a. Real Estate Development? Yes No
b. The manufacture, sale or distribution of any product or process or patented production process? Yes No
Project Information: List the percentage of your organization’s receipts estimated for the next 12 months from the following project types. (Total of all percentages must equal 100%.)
Airports / % / Landfills/Solid Waste Facilities / % / Recreational/Sports / %Apartment / % / Libraries / % / Residential* / %
Bridges / % / Manufacturing/Industrial / % / Roads/Highways / %
Churches / % / Mass Transit / % / Schools/Colleges / %
Dams / % / Military Facilities / % / Shopping Center/Retail / %
Dormitories / % / Mines / % / Site Development / %
Food Processing / % / Mixed Use Residential/Commercial / % / Storm Water Systems / %
Harbors/Piers/Ports / % / Nuclear / % / Tunnels / %
Hospitals / % / Office Buildings / % / Warehouses / %
Hotels/Motels / % / Parking Structures / % / Wastewater Systems / %
Homes/Town Homes / % / Petro/Chemical/Refinery / % / Waste Treatment Plants / %
Industrial Waste Treatment / % / Potable Water Systems / % / Utilities / %
Jail/Justice / % / Power Plant / % / Other (Specify) / %
*Residential includes: Single family homes, multi-family homes, residential condominiums, assisted living facilities.
TOTAL (All percentages must add to 100%) / 100%
17. What percentage of your firm's revenue is derived from repeat clients? / %
18. What percentage of your firm's revenue is derived from your largest client? / %
19. Does your insured have a financial/equity interest in any projects? Yes No
20. Do you provide any of the following services?
a. Website design or website programming Yes No
b. Database design or management, data warehousing, data application hosting Yes No
c. Maintenance of computer programs, applications or systems designed or developed by you Yes No
d. Design and/or development of computer software programs, systems, or applications Yes No
e. Creation, maintenance, use, modification, input into any digital model or digital representation Yes No
CONSTRUCTION MANAGEMENT INFORMATION
21. Do you perform construction management services? Yes No
Construction Management Services, which you perform:
(Estimated billable fees to others and include all internal allocations for work you self perform):
a. Cost Management: / $b. Scheduling/Project Coordination: / $
c. Constructability Reviews: / $
d. Inspections: / $
e. Testing: / $
f. Other (describe fully):
22. Do you, any subsidiary or related entity, perform construction activities for projects for which you
also perform construction management services? Yes No
23. When performing construction management services, do you assume responsibility for site safety? Yes No
24. When performing construction management services, do you contract directly with the contractors
responsible for construction? Yes No
DESIGN BUILD INFORMATION
25. Do you perform work under design/build contracts? Yes No
If yes, what type of projects have you been involved in?26. When performing work under a design/build contract:
a. Are you the architect/engineer/designer of record? Yes No
b. Are you directly performing any architect, engineer or design services? Yes No
27. Do you perform environmental/pollution remediation design services or handling, containment or
disposal protocols for others? Yes No
SUBCONTRACTORS - PROFESSIONAL LIABILITY INFORMATION
28. If you subcontract design services, please indicate the names of the architect or engineer that you most often use and their
professional liability carrier and limits:29. Do you secure certificates of insurance from the architect/engineering subcontractors evidencing their
professional liability coverage? Yes No
30. Do you have minimum limits of professional liability coverage required to be carried by architect/engineering
subcontractors? Yes No
31. Does your certificates of insurance program maintain current in-force certificates of architect/ engineering subcontractor’s professional liability insurance for their work for you that has been completed? Yes No
If yes, how long?32. Does your certificates of insurance program require notice of cancellation, non-renewal, or material
change of the architect/engineering subcontractor’s professional liability insurance for all of their
current work for you and all of their work for you that has been completed? Yes No
33. Does your subcontract require the architect/engineering subcontractor to indemnify you for loss
resulting from their acts, errors or omissions? Yes No
34. Do you require that you be named as additional insured on your subcontractor GL policies? Yes No
35. What percentage of your firm’s professional services is performed under written contracts? / %Type of contract used:
a. / a. U.S.: AIA or AGC standard forms of agreement / %b. / b. Canada: ACEC, CCAC or CCDC standard forms of agreement / %%
c. / c. International: FIDIC standard forms of agreement / %
d. / d. Other (please specify) / %
36. How are client and/or subcontract agreements reviewed and negotiated? Please check all that apply.
Attorney – Outside Insurance Broker or Agent Reviews
Attorney – In-House Other
37. Do you provide Value Engineering Services?
a. Directly Yes No
b. Subcontracted Yes No
If yes, describe any projects that were high tech, or involved radically designed products:
39. Are all products and material modifications documented and approved in writing by the owner,
architect and engineer, and subcontractors? Yes No
40. Do the personnel involved in Value Engineering have the certified quality engineer designation? Yes No
RISK CONTROL INFORMATION
41. Do you have a dedicated Risk Manager and/or Safety Officer? Yes No
42. Do you utilize written, in-house quality control procedures? Yes No
43. How often are those procedures updated?44. Do you utilize written, in-house health and safety procedures? Yes No
45. Are formal change order provisions utilized? Yes No
46. List professional society memberships:
AGC ABC NUCA ASSE DBIA CFMA CMMA
Other (please specify):HISTORY INFORMATION
47. Do you currently maintain contractors professional liability insurance coverage? Yes No
If previous coverage has been purchased, please complete history below:
Contractors Professional Liability Coverage History:
Year / Carrier / Occurrence or Claims-Made / Retroactive Date (if applicable) / Limits / Deductible/SIR / Incurred claims:
Paid and
Reserved / Premium
Date that uninterrupted claims-made Contractors Professional Liability insurance began:
48. Are any coverage limits purchased under the previous coverage that is subject to the requested retroactive date
LESS THAN the coverage limit being applied for? Yes No
49. Have you ever been declined for contractors professional liability insurance, or has any
such coverage ever been cancelled, or non-renewed? Yes No
50. Are you aware of any circumstances or incidents which may result in a claim being filed against any
proposed named insured company? Yes No
CURRENT OTHER LIABILITY INSURANCE PROGRAM INFORMATION
51. / Carrier / Retroactive Date(if applicable) / Limits and
Deductible/SIR
Commercial General Liability
Is coverage currently with or being quoted by Travelers?
Yes No
Local Travelers U/W Contact:
Umbrella/Excess Liability
Contractors Pollution Liability
Occurrence Claims-Made
CLAIM REPORTING INFORMATION
52. What are your claim reporting and investigating procedures for professional liability claims or incidents?
53. Please describe any professional liability claims that have been made against you, or any individual holding a management or supervisory position with you, during the last seven years and any acts, errors or omissions which have been committed during the last seven years, which are known, and which could reasonably give rise to such a future professional liability claim. If none, please indicate this in your response.
NETWORK AND INFORMATION SECURITY LIABILITY (NAISL)
54. Within the past 2 years, has any proposed named insured:
a. Sustained any systems intrusion, virus attack, hacking incident, data theft, or similar event? Yes No