• Architects/ Engineers/ Land Surveyors/ Environmental Consultants

    E&O Insurance Application
  • Type of Entity:
  • Date Firm Commenced Operations
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  • Format: (000) 000-0000.
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  • 3. Has the applicant or any subsidiary in the past three years been involved with, or contemplated in the next 12 months any merger,acquisition or divestment? If yes, please describe details in question #21.
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  • 7a. Have you ever provided services outside the USA, its territories and possessions and Canada?
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  • Project Types

  • 10. Types of Projects as a percent of your Gross Revenues. Total = 100

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  • 11. Largest Current Projects

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  • 12. CONTRACTS/RISK MANAGEMENT

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  • g) Does your firm have non-standard contracts reviewed by legal counsel or your insurance provider for liability implications prior to signing?
  • j) Does your firm provide continuing education and training programs for its professional and technical staff?
  • l) Are any principals or employees of your firm members of any professional associations? (AIA, ASCE, ACEC, NSPS, etc.)

  • 13. Special Circumstances

  • a) In the past three years have you brought suit to collect any fees?
  • b) Has your firm or any subsidiary or predecessor firm ever filed for or been in receivership or bankruptcy under Chapter 7 or Chapter 11?
  • c) Does your firm (or any related firm) perform actual construction, erection or fabrication?
  • d) Does your firm (or any related firm) engage in computer software development for or sale to others?
  • e) Does your firm (or any related firm) engage in Real Estate Development?
  • f) Does your firm (or any related firm) engage in the manufacture, sale, leasing or distribution of any product or production process?
  • g) Do you or any principal, owner or officer, director or an immediate family member have an ownership interest in any entity for whom professional services are being rendered?

  • If the answer to any item under question #13 is Yes, please provide details under question #21. Additional Information.

  • 14. Do do you require all of your subconsultants to purchase Professional Liability Insurance with a limit of $1 million or more?

  • Insurance

  • 15. Does your firm currently carry Professional Liability Insurance?
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  • 16. Is your firm a named insured under a project policy?
  • 17. Have you or any principal, partner, officer, director, or shareholder of your firm ever been declined for Professional Liability Insurance or had such coverage canceled (except for nonpayment of premium)or non-renewed?

  • If yes, please provide details in Additional Information, question #21.

  • Claims. It is important to report claims as well as situations of which you are aware that may give rise to a claim during the policy period in which you are first aware of them. The policy that you are applying for will not cover claims or situations that you are aware of prior to the effective date.

  • 18. Have any claims, proceedings or suits ever been made or threatened in the past five years against the Applicant or any entity intended to be covered or any present or former directors, officers, trustees or employees:

  • In the past 5 years?
  • In the past 10 years?
  • 19. Is the Applicant or any entity or person intended to be covered aware of any negligent act, error or any other fact, circumstance or situation which may reasonably be expected to give rise to a claim against it or any of its directors, officers, trustees or employees?

  • If yes to either question, please complete a Claim Report for each claim

  • Claim Reports

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  • Additional Information

  • The Applicant declares that, after inquiry, to the best knowledge of all persons to be insured the statements set forth herein and in any attachments hereto are true and no material facts have been suppressed, omitted or misstated. Underwriters reserve the right to amend the terms, conditions and limitations of any policy issued as a result of this application if, subsequent to the date of this application, but prior to the inception of such policy, there are any material alterations to the information contained herein. Completion of this application does not bind the Underwriter to provide coverage, but it is agreed that the statements and particulars contained herein will be relied upon by Underwriters in the event the policy is issued.

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