Architects/ Engineers/ Land Surveyors/ Environmental Consultants
E&O Insurance Application
Firm Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Entity:
Corporation
Partnership
LLP
LLC
Sole Proprietorship
Joint Venture
Other
Date Firm Commenced Operations
-
Month
-
Day
Year
1
Federal Tax ID #
Website
Insurance Contact
Title
Email
Phone Number
List all preexisting entities, Including mergers and acquisitions, with their dates of existence.
Entity
From
To
#1
#2
#3
#4
Back
Next
2. Size of Staff
Licensed Principals
Non-Licensed Principals
Other Licensed Staff
Technical - Not Licensed
Admin
Total
Staff Count - FTEs
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.
Yes
No
4. Firm's annual Gross Revenues for the past three years?
Projected
Last Year*
2 years ago
3 years ago
Gross Revenues
Subconsultants
Direct Reimbursable Expenses
Net Revenues
Feasibility Studies
Projects that have been abandoned
Projects Insured under separate project policies
Joint Venture projects (your portion of JV Billings)
*Last Full Fiscal Year
Enter beginning and end dates for the last full fiscal year
5. Your disciplines as a percentage of Net Revenues
Percent
Architecture
Chemical Engineering
Civil Engineering
Commissioning/Testing
CM - Agency
CM - At Risk
Drafting
Electrical Engineering
Environmental Consulting
Environmental Permitting
Forensics
Geotechnical Engineering
HVAC Engineering
Hydrology/Geology
Interior Design
Laboratory Testing
Based on Last Year's Net Revenues. Total = 100
Percent
Landscape Architecture
Land Surveying
Land Surveying - Construction Staking
Land Surveying - Topographic/Boundary
Land Surveying - Other*
Land Use Planning
Marine Engineering
Mechanical Engineering
Mining Engineering
Naval Architecture
Process Engineering
Structural Engineering
Telecommunication Engineering
Traffic Engineering
Other #1*
Other #2*
Total
*Land Surveying - Other
*Other #1
*Other #2
Back
Next
6. Services provided by your firm. Total = 100
Percent
Design Service (w/o Construction Phase Services)
Design with Construction Observation Services
Design with Responsibility for Construction
Construction Management w/o Design Services
Percent
Feasibility Studies/ Planning Reports
Inspections
Surveying, Mapping, Flood Plain Studies
Total
7a. Have you ever provided services outside the USA, its territories and possessions and Canada?
Yes
No
7b. What percent of your firm's annual Gross Revenues for the past year was derived from projects outside the USA, its territories and possessions and Canada?
If Yes, please provide details
8. What percent of your firm annual gross revenues for the past year was derived from each of the following categories of Owners? Total = 100
Federal
State & Local Government
Institutional
Private
Total
Percent
9. What percent of your firm annual gross revenues for the past year was derived from each of the following categories of clients? Total = 100
Contractors
Developers
Owners/ Governments
Design Firms
Total
Percent
Project Types
10. Types of Projects as a percent of your Gross Revenues. Total = 100
Residential Projects
Percent
Apartments
Condominiums
High Rise Apartments
(7 or more stories)
High Rise Condos
(7 or more stories)
Mixed Use (Residential/Commercial)
High Rise Mixed Use
(7 or more stories)
Townhouses
Single Family Homes
Residential Subdivisions
Commercial Projects
Percent
Office Buildings (less than 15 Stories)
High Rise Office Buildings
(more than 15 stories)
Hotels/ Motels/ Resorts/ Timeshare
Retail Stores/ Shopping Centers
Parking Garages
Parks / Golf Courses
Museums
Stadiums/ Arenas
Swimming Pools
Amusement Parks, Zoos
Infrastructure Projects
Percent
Airports/Runways
Bridges/ Trestles/ Tunnels
Dams/ Reservoirs
Harbors/ Jetties/ docks/ Piers/ Ports
Roads/ Highways
Nuclear
Passenger Transportation Terminals
Power Plants (non-nuclear)
Off Shore Structures
Telecommunications
Transmission Lines, Power Utilities
Water System Distribution
Wastewater collection/ water reclamation systems
Wastewater/ Water Treatment Plants
Environmental Projects
Percent
Preliminary Site Assessments
(Phase I)
Environmental Site Assessments
(Phase II)
Remedial Design
(Phase III)
Site Remediation/ UST removal
Asbestos & Mold Abatement
EIS/ EIR (CEQA/NEPA)
Air Quality/ Noise Studies
Cultural Resources
Habitat/ Biological/
Wetland Studies & Design
Institutional Projects
Percent
Churches
Colleges & Universities
Hospitals, Healthcare,
Convalescent
Jails/ Prisons
Military Facilities
Schools (through grade 12)
Industrial Projects
Percent
Industrial/ Manufacturing Buildings
Industrial waste treatment
Machinery, products
Mines, quarries
Petrochemical plants
Pipelines
Research and development laboratories
If any portion of your projects do not fit well into the categories provided above (Misfits), please describe them below:
Project Category
Project Type
Misfit #1
Residential
Commercial
Infrastructure
Environmental
Institutional
Industrial
Misfit #2
Residential
Commercial
Infrastructure
Environmental
Institutional
Industrial
Misfit #3
Residential
Commercial
Infrastructure
Environmental
Institutional
Industrial
Misfit #4
Residential
Commercial
Infrastructure
Environmental
Institutional
Industrial
If any portion of your projects do not fit well into the categories provided above (Misfits), please enter percent of Gross Revenues below:
Percent
Misfit #1
Misfit #2
Misfit #3
Misfit #4
Grand Total
11. Largest Current Projects
Attach a list of your firm's 5 largest current projects; include 1) project name, 2) client name, 3) project location, 4) project description, 5) services you are providing, 6) your estimated total gross receipts for the project, 7) estimated project construction value and 8) estimated year the project will be completed.
Browse Files
Drag and drop files here
Choose a file
Please attach a word document, PDF or spreadsheet
Cancel
of
Back
Next
12. CONTRACTS/RISK MANAGEMENT
a) Please indicate applicant’s gross revenues in percentages by type of contract. Total must equal 100.
Professional Association Contract
Firm's Standard Contract
Letter Agreement
Purchase Order
Client's Agreement
Oral Agreement
Total
Percent
Please attach a copy of your firm's standard contract.
Browse Files
Drag and drop files here
Choose a file
Please attach a word document or PDF
Cancel
of
b) Estimate the percentage of your gross revenues for the past fiscal year was derived from repeat clients?
c) What percentage of the work performed by subconsultants is performed underwritten contracts?
d) When you hire subconsultants, for what percentage of those projects do you obtain professional liability certificates of insurance from your Subs?
Please attach Subconsultant insurance certificates for your 3 largest Subsconsultants
Browse Files
Drag and drop files here
Choose a file
Cancel
of
e) What percentage of your professional services contracts with clients have a limitation of liability clause?
f) What percentage of your firm’s current contracts contain a limitation of liability % clause less than or equal to $250,000?
g) Does your firm have non-standard contracts reviewed by legal counsel or your insurance provider for liability implications prior to signing?
Yes
No
h) What percent of your Gross Revenues was derived from projects utilizing BIM or virtual design and construction modeling?
i) What percent of your Gross Revenues are on projects designed to meet a Green Building LEED certification?
j) Does your firm provide continuing education and training programs for its professional and technical staff?
Yes
No
k) What percent of your firm’s licensed staff have participated in risk management training in the last fiscal year?
l) Are any principals or employees of your firm members of any professional associations? (AIA, ASCE, ACEC, NSPS, etc.)
Yes
No
13. Special Circumstances
a) In the past three years have you brought suit to collect any fees?
Yes
No
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?
Yes
No
c) Does your firm (or any related firm) perform actual construction, erection or fabrication?
Yes
No
d) Does your firm (or any related firm) engage in computer software development for or sale to others?
Yes
No
e) Does your firm (or any related firm) engage in Real Estate Development?
Yes
No
f) Does your firm (or any related firm) engage in the manufacture, sale, leasing or distribution of any product or production process?
Yes
No
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?
Yes
No
If the answer to any item under question #13 is Yes, please provide details under question #21. Additional Information.
Back
Next
14. Do do you require all of your subconsultants to purchase Professional Liability Insurance with a limit of $1 million or more?
Yes
No
If No, what percent of your subconsultants expense is paid to uninsured or under-insured (< $1 million limit) subconsultants?
If No, describe your reasons for not requiring subconsultants to carry Professional Liability Insurance or for accepting low limits of coverage?
Insurance
15. Does your firm currently carry Professional Liability Insurance?
Yes
No
If IOA is not your current insurance agent, please attach a copy of your current Professional Liability Insurance policy's Declarations page.
Browse Files
Drag and drop files here
Choose a file
Attached a PDF of your PLI policy's declarations page
Cancel
of
16. Is your firm a named insured under a project policy?
Yes
No
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?
Yes
No
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?
Yes
No
In the past 10 years?
Yes
No
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?
Yes
No
If yes to either question, please complete a Claim Report for each claim
Claim Reports
20. For each claim please provide: 1) name of claimant, 2) a description of the claim, 3) date the claim was made, 4) the name of the insurance company the claim was reported to, 5) is the claim open or closed, 6) the claimant's demand or the settlement amount, 7) the claim's defense expenses and 8) if still open, the like settlement amount.
Browse Files
Drag and drop files here
Choose a file
Please attach a word doc or PDF for each claim.
Cancel
of
Additional Information
21. This area may be used to provide helpful insights about your firm, its risk management practices, as well as to provide additional information to any question on this application. When providing additional information, please reference the question number.
Specifically, if necessary, provide details about question #3 regarding contemplated Merger and Acquisitions, question #13 regarding Special Circumstances, and question #17 regarding any prior declination of insurance.
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.
Type a question
Name of Applicant
Title
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: