Insurance Instruction Form /

Firm Name:

I. Property PortionRequested Limits

Contents - Furniture & Fixtures / $
Leasehold Improvements / $
Computers – Hardware & Software Combined / $
Valuable Papers including Computer Software – Additional Information Required –
See Question #7 on Next Page / $
Storage –Off Premises / $
Scheduled Equipment That Goes Off-Premise – Excluding Computers (Please Provide a List of Equipment including Serial Numbers and Cost) / $
Scheduled Fine Arts (Please Provide a List including Appraised Value) / $
ERISA Trust Compliance Bond (Retirement Plan) List Plan Name and Values (10% of the Total Plan’s Assets) / $

Address of Property Location:

Year Building Built:

Number of Stories of the Building:

Construction Type of Building:

Square Footage of EntireBuilding:

Square Footage of Office Space Occupied by Insured:

Is there a Fire and/or Burglar Alarm System?

If Building is Older than 15 Years: Please provide the year of building updates

completed:

Plumbing ______Electrical ______Roofing ______Heating ______

II. General Liability

Number of employees at premises:

**** Total # employees of the office / ______

Additional Insured endorsements: Attach list of additional insureds needed

III. Umbrella/Excess Limits of Liability

Limit of Liability / $

IV. Commercial Automobile:

Limit of Liability - CSL / $
(Including Hired & Non-Owned Auto Liability)
Uninsured Motorists/Underinsured Motorists / $
Personal Injury Protection / $
Physical Damage:
Collision Deductible / $
Comprehensive Deductible / $
Owned Vehicles: Attach schedule – if needed
(Make, Model & FULL Vehicle Identification Number)
1)
2)
3)
4)
5)
Drivers: / License #: / Date of Birth:

V. WORKERS COMPENSATION

Firm’s Tax Identification Number: ______

ANNUAL PAYROLL BY CLASS CODE

CLASS CODE / NUMBER OF EMPLOYEES / DESCRIPTION / EST. ANNUAL PAYROLL
8601 / ARCHITECT/ENGINEER / $
8601 / FIELD SURVEYOR / $
8810 / DRAFTSMEN / $
8810 / CLERICAL / $
8809 / EXECUTIVE OFFICER / $

*** THIS OWNERSHIP INFORMATION MUST BE COMPLETED ***

PARTNERS / OFFICERS TO BE INCLUDED OR EXCLUDED

OWNER NAME / AGE / TITLE / INC/EXC / CLASS / PAYROLL
  1. ARCHITECTS/ENGINEERS = All architects/engineers and employees that go out of office to job/construction/ project sites; they do not have to be a professional architect/engineer to be classified as an architect/engineer. A draftsman that goes out of the office to job/construction/project sites/meetings.
  1. DRAFTSMEN = employees that stay in office, performing drafting and/or architect/engineering work.
  1. EXECUTIVE OFFICERS = use maximum $ 62,400 per exec. officer or true payroll if less. If exec. officer is an architect/engineer by definition, put payroll in the architect/engineering class if they go out of the office even one time a year for any type of meeting. (If PARTNER or SOLE PROPRIETOR use maximum payroll of $50,200.)

QUICKBOOKS USER for Payroll? YES NO

If Yes, would you like to apply for XactPay Web, that automatically calculates premium based upon your actual Payroll? (Eliminates large down payment and year-end audits) YES NO

PLEASE PROVIDE THE FOLLOWING INFORMATION:

  1. Do you perform any construction work either directly, or do you sub-out

any construction work? Yes No

  1. Do you perform any stand-alone construction management service?

Yes No

  1. Do you perform any operations other than that which would be

normally provided by an architect, engineer or environmental

professional? Yes No

4. Do you perform any site remediation? Yes No

5. Do you use a boat(s) to perform a job for a client? Yes No

(If yes, please provide details.)

  1. Is there any synthetic stucco construction or EIFS

(exterior insulation and finish systems) at this location? Yes No

  1. Please provide the address for all locations, including off site storage,

of the valuable papers and records.

______

______

  1. Do you have any employees who travel outside of the U.S. ? Yes No
  1. Do you have any interest in obtaining a quote for Employment Practices Liability (discrimination, harassment, wrongful termination, etc.) Yes No
  1. Do you have any interest in obtaining Directors and Officers Liability

(shareholder suits)? Yes No