Application - Project Specific Professional Liability for Design Professionals

Application - Project Specific Professional Liability for Design Professionals

PROJECT SPECIFIC PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR DESIGN PROFESSIONALS

  1. Please answer all questions completely.
  2. If there is insufficient space to complete an answer, please continue on a separate sheet of the firm’s letterhead. Indicate number of question.
  3. Attach a copy of the contract for this project
  4. This form must be completed, signed, and dated by a principal, partner or officer of the firm.
  5. Please type or print.

NOTE:
The insurance for which you are applying is written on a CLAIMS-MADE AND REPORTED basis; only Claims first made against the Insured and reported to the Company during the Policy Period are covered subject to the Policy Provisions. / The Limits of Liability stated in the Policy are reduced, and may be exhausted, by Claims Expenses. Claims Expenses are also applied against your Deductible, if any. If you have any questions about coverage, please discuss them with your insurance broker.
1. APPLICANT INFORMATION

a.Name of applicant::

b.Principal address:

Telephone number:

c.Services to be provided:

d.Coverage requested:

(i)Limit(per claim):

(ii)Aggregate:

(iii)Deductible:

(iii)Design Period:

Construction Period:

Extended Reporting Period:

2.PROJECT INFORMATION

a. Name and/or designation of project:

b. Location of project:

c. Name of project’s prime professional, if other than yourself:

d. Name and address of owner of project:

e.Name and address of client for whom you will provide professional services:

f.Please describe nature of project (use separate sheet if necessary):

g.Does this project incorporate any untried and/or untested technology:

YesNo

If yes, please give details:

h. Duration of project by phase using dates:

StartCompletion

Schematic Design
Schematic Design
Construction Documents
Bidding or Negotiation
Construction

i. Total project fees (including fees paid to consultants) for the following services (total = 100%):

Acoustical Engineering / % / Forensic Engineering / % / Process Engineering / %
Architecture / % / HVAC Engineering / % / Soils Engineering / %
Civil Engineering / % / Interior Design / % / Structural Engineering / %
Communication Engineering / % / Laboratory Testing / % / Traffic/Transportation / %
Construction Management / % / Land Surveying / % / Other (describe below) / %
Electrical Engineering / % / Landscape Architecture / %
Environmental Engineering / % / Mechanical Engineering / %

j.Total estimated project construction value:

Total Estimated Project Fees (including fees paid to consultants):

k.Name and address of the general contractor and/or construction manager for the project, if awarded:

3.CONSULTANTS

a.Please complete the following for all of your consultants rendering services in connection with this project. (A consultant should be shown for each service listed in question 2(h) above that you do not perform).

NAME AND ADDRESS / TYPE OF SERVICE / FEES






b.Equity Interest: After inquiry of each of your consultants, do you or any of your consultants, parent company, subsidiary or otherwise related entity retain an ownership interest in this project? Yes No If yes, please attach details including the full name of all parties having an ownership interest in the project and the percentage of ownership for each.

c.After inquiry of each of your consultants, do you or any of your consultants, parent company, subsidiary or otherwise related entity plan to engage in actual construction, manufacturing, fabrication, or the supply of materials for this project? Yes No If yes, please give details:

d.Please list Professional Liability Insurance for yourself and your consultants:

Firm Insurance Company Limit Deductible Effective Date

Applicant
Consultant i
Consultant ii
Consultant iii
Consultant iv
Consultant v
Consultant vi

e.After inquiry of each of your consultants, has any application for Professional Liability Insurance made on behalf of yourself or any of your consultants ever been declined or has any such insurance ever been canceled or renewal refused? Yes No If yes, please give details:

f.Please attach a copy of your Client Agreement and your Consultant Agreements used for this project.

4.CLAIMS

a.After inquiry of each of your consultants, are you or any of your consultants aware of any circumstances which may result in any claim under the requested insurance? Yes No

If yes, please state briefly the cause and nature of the claim, including the amount involved and the claimant, the date when the claim was made, the date the act giving rise to the claim was committed and the final disposition:

It is agreed that if there is knowledge of such circumstances, any claim subsequently arising therefrom will be excluded from coverage under the requested insurance.

5.ACKNOWLEDGEMENT

The undersigned authorized officer on behalf of the Applicant:

  • Declares that the statements and disclosures in this application are complete and accurate;
  • Declares that there are no known facts or material to the risk to be insured that have not been disclosed in this application;
  • Undertakes to provide the Company immediate notice of any material changes discovered between the date of this application and the effective date of the policy;
  • Acknowledges that the Company, if it issues, the policy will be doing so in reliance of the completeness and accuracy of the statements and disclosures in this application;
  • Acknowledges that if issued, this application will form part of the policy.
  • Acknowledges that any personal information provided in connection with the coverage applied for, including but not limited to the information contained in this application, has been collected in accordance with all applicable privacy legislation. The undersigned confirms that all necessary consents have been obtained for the collection, use, and disclosure of such information for the purposes of assessing the application for insurance, and if applicable, investigating and settling claims, detecting and preventing fraud, and acting as required or authorized by law.
  • For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Liberty Mutual Insurance Company’s insurance business in Canada.

NAME: / TITLE:
SIGNATURE: / DATE:
(Principal, Partner, or Officer)

Note: This application must be reviewed, signed and dated by a principal, partner or officer of the applicant firm.

A&E Project Specific Professional Liability (02/13)Page 1 of 3

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