LLOYD’S OF LONDON

APPLICATION FOR ARCHITECTS/ENGINEERS PROFESSIONAL LIABILITY INSURANCE WITH CERTAIN UNDERWRITERS AT LLOYD’S

THIS APPLICATION IS FOR A CLAIMS MADE INSURANCE POLICY

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime.

APPLICANT’S INSTRUCTIONS

1.		ALL QUESTIONS MUST BE ANSWERED COMPLETELY; PLEASE TYPE OR PRINT CLEARLY; IF ANY QUESTIONS ARE CONSIDERED “NOT APPLICABLE”, PLEASE EXPLAIN WHY
2.		IF YOU NEED MORE SPACE, CONTINUE ON A SEPARATE SHEET AND INDICATE QUESTION NUMBER
3.	PLEASE COMPLETE SUPPLEMENTS WHERE REQUIRED
4.		THIS APPLICATION AND ALL SUPPLEMENT FORMS MUST BE SIGNED AND DATED BY A PRINCIPAL OF THE FIRM.

1.	Name of Applicant:

Proprietorship:	Partnership:	Corporation:

2.	Address:

City:	County:

State:	Zip:

3.	Telephone:

4.	Branch Office Address(es) – use a separate addendum if applicable

5.	Date Established:  (current entity)	 	

PERSONNEL
6a	Number of Staff	Last Year 	This year

Principals/Partners/Directors

Other Licensed Professionals

Other Staff:

Total Licensed Professionals

b.	Please indicate the applicant’s annual staff turnover:

c.	Please attach Resumes of key Principals

GROSS BILLINGS

Total Gross Billings for professional services (whether collected or not) to include reimbursable expenses and sub- consulting fees

Professional Services

7a	Joint Venture projects

Total Gross Billings (including Billings Attributable to Consultants

Construction Values (pro-rate for Multi-year projects)

(Your portion of JV billings)	$	 	$    	
b	Projects Insured under separate Project Policies

c	Projects which have been permanently

$	 	$    	

abandoned:	$	 	$    	

d	Feasibilities studies, master plans, reports, opinions or interior design. NOTE: Interior design refers to interior non-structural services such as space planning and the selection of furniture, fixtures and finishes, it does not include services associated with renovations (other than space planning):

$	 	$    	

e
Landscape Architecture:	$	 	$    	

f	Land Survey:	$	 	$    	

g	Direct reimbursables by contract (i.e. travel per diem, billings for reproduction, etc. Do not include consultants
$	$

h	All other billings	$	$ TOTAL PAST ACCOUNTING YEAR
A+B+C+D+E+F+G+H)	$
i

j	Three year gross receipts (to include reimbursable expenses and sub consulting fees)

Fiscal Year	Month	/	Year

Current Fiscal Year	20	$

Last Fiscal Year	20	$

Estimated Next Fiscal Year	20	$

8
Please indicate percentage of the Applicant’s gross billings derived from projects	%
outside the U S A and Canada

9
Were more than 25% of the Applicant’s billings during the past fiscal year
derived from a single client or contract?

Yes	No

  If yes then please provide details: 	

PROFESSIONAL DISCIPLINES

10	Specify as a percentage of the Applicant’s Gross Billings (Total must equal
100%)

Architecture	 	%	Landscape Architecture	 	%	HVAC Engineering	 	%	
Civil Engineering	 	%	Land Surveying	 	%	Marine/Coastal Engineering	 	%	
Mechanical Engineering	 	%	Construction Management	 	%	Nuclear Engineering	 	%	
Electrical Engineering	 	%	Process Engineering	 	%	Mining Engineering	 	%	
Structural Engineering	 	%	Chemical Engineering	 	%	Interior Design	 	%	
Soils Engineering	 	%	Environmental*	 	%	Land Use Planning	 	%	
Laboratory Testing	 	%	Hydrogeology/geology	 	%	Design/Build **	 	%	

*   If yes Supplement 1 must be submitted
** If yes Supplement 2 must be submitted

11	Please indicate the percentage of the Applicants billings derived from work performed on a “fast Track”
basis, i.e. those project in which construction begins before design is complete:
 	%

12.	Please indicate percentage by fees of current projects where the construction contract is a: Bid contract:	 	%
Negotiated contract:	 	%

13	Please indicate the percentage of the Applicant’s billings derived from repeat business	 		%

PROJECTS
14	Please indicate types of projects as a percentage of the Applicant’s Gross Billings:
a	Schools, colleges or public
buildings	 	%	m	Water Systems
 	%	
b	Hospitals, retirement homes or
convalescent hospitals	 	%	n	Bridges, trestles or tunnels
 	%	
c	Hotels, motels or resort properties
 	%	o	Land reclamation design
 	%	
d	Condominiums
 	%	p	Structures for offshore use
 	%	
e	Garages, theatres or grandstands
 	%	q	Harbours, jetties, docks or piers
 	%	
f	Shopping centers
 	%	r	Machinery design/mechanical
design	 	%	
g	Office/mercantile/commercial
buildings	 	%	s	Earth dams, reservoirs
 	%	
h	Public Utilities or industrial
buildings	 	%	t	Pipelines
 	%	
i	Single family residential
 	%	u	Petrochemical
 	%	
j	Custom single family residential
 	%	v	Mines and quarries
 	%	
k	Apartments and other multi-unit
residential	 	%	w	Nuclear projects
 	%	
l	Sewage or waste disposal systems
 	%	x	Other (please specify)
 	%	

15	Please complete Supplement 3 (Largest Projects)

16	Please attach a copy of your Company’s brochure

SERVICES

17	Please indicate percentages of the Applicant’s Gross Billings derived from each of the following: (Total must equal 100%)

a	Design with construction review	 		%	
b	Design without construction review	 		%	
c	Construction review without design	 		%	
d	Project or construction management	 		%	
e	Feasibility, economic or other studies	 		%	
f	Boundary surveying	 		%	
g	Sub-surface soils testing, soils analysis, ground testing	 		%	
h	Material testing	 		%	
i	Foundation design	 		%	
j	Interior design/space planning	 		%	
k	Forensic/Expert witness	 		%	
l	Other (please specify)	 		%	

CONTRACTS

18	Please indicate types of contracts utilised by Applicant (Total must equal 100%)

a	
Standard industry contract (ACEC,AIA, ASFE, etc)	
 		
%	
b	Firm’s standard contract	 		%	
c	Letter agreement	 		%	
d	Purchase order	 		%	
e	Client contract	 		%	
f	Oral agreement	 		%	

19	Please submit a copy of a typical contract of hire utilised by the Applicant

CLIENTS

20	Please indicate percentage of the Applicant’s gross Billings attributable to the following types of clients
(Total must equal 100%)

A	Government or Public Entities, Federal, State, County or Local	 		%	
B	Owners acting as their own builders	 		%	
C	Turnkey contractors *	 		%	
D	Design/build contractors *	 		%	
E	Other contractors *	 		%	
F	Developers	 		%	
G	Financial and lending institutions	 		%	
H	Other design professionals	 		%	
I	Other (please specify)	 		%	

*	Please detail steps taken in order to avoid contractor or owner contractor litigation

FINANCIAL AND RELATED INTERESTS

21	During the past twelve months, has the Applicant or any subsidiary, parent or other organisation related thereto, being engaged in:

A	Actual construction, fabrication or erection	Yes	 		No	 		
B	Development, sale or leasing of computer software	Yes	 		No	 		
c	Real Estate development	Yes	 		No	 		
d	Manufacture, sale, leasing or distribution of any product, profess or					
	patented production profess	Yes	 		No	 		
e	Design of a building, component or system which might be used on					
more than one project	Yes	 	No	

22	
Has the Applicant entered into any Joint Venture?	
Yes	
 		
No	
 		
	Is Joint Venture coverage required?	Yes	 		No	 		
	(If yes, Supplement 4 must be submitted)					

23	
Does the Applicant or any principal have any financial interest in any					
	projects for which it has provided professional services?	Yes	 		No	 		
	Is coverage for Equity interest required?
(If yes, Supplement 5 must be submitted)	Yes	 		No	 		

24	
Does the Applicant have any abandoned projects?	
Yes	
 		
No	
 		
(If yes, please give full details by attachment)

SUBCONTRACTORS/CONSULTANTS

25	Please indicate types and percentages of work the Applicant subcontracts to others:

a	Architecture	 	% 		Soils	 	% 		
	Civil	 	% 		Structural	 	% 		
	Mechanical	 	% 		HVAC	 	% 		
	Electrical	 	% 		Other (please specify)	 	% 		

b	Please describe the process by which the Applicant selects subcontractors and sub-consultants:

c	Are written contracts used for all subcontractors and sub-consultants?

Yes	 	No	 	

d	Do the Applicants contracts with subcontractors and sub-consultants contain indemnification and hold harmless provisions?
Yes	 	No	 	

e	Does the applicant obtain certificates of insurance from all subcontractors and sub-consultants?
Yes	 	No	 	

f	Is the applicant named as an Additional Assured under all subcontractor and sub-consultant General
Liability Policies?
Yes	 	No	 	

MANAGEMENT

26	a	Does the Applicant have an in-house
quality control procedure?	Yes	 	No	 	

b	Is it in written form?	Yes	 	No	 	

c	Are all appropriate staff members
familiar with these procedures?	Yes	 	No	 	

d	Has the firm been given an independent peer review in the last 24 months?

Yes	No

27	Has the name of the Applicant changed or has any other firm or organisation been merged or amalgamated with or into the Applicant, or is any such change pending?

If yes, please give full details by attachment

Yes	 	No     	

28	Is the Applicant controlled, owned by or associated with, or does the Applicant control or own any other entity?

If yes please give full details by attachment

Yes	 	No     	

LOSS HISTORY

29	a	After enquiry, have any claims or suits been made against the Applicant? (Please include those claims arising from separately insured projects)

If yes, Supplement 6 must be submitted

Yes	 	No     	

b	After enquiry, are any member(s) of the Applicant aware of any circumstances, allegations or contentions as to any incident which may result in a claim being made against the Applicant?
Yes	 	No     	
If yes, Supplement 6 must be submitted

c	Has the Applicant or any principal been the subject of disciplinary action by authorities as a result of their professional activities?

If yes, please give details by attachment

Yes	 	No     	

INSURANCE

30	Has insurance of the type for which the Applicant is now applying ever been declined, cancelled or had the renewal thereof refused?

If yes please give details by attachment

Yes	 	No     	

31	Please give details of previous insurance (past five years):

Carrier	Policy No.	Limits Each
Claim/aggregate

Deductible	Paid
Premium

Effective
From	To

1  		 		  $ 		  $ 	$ 		 	
2  		 		  $ 		  $ 		  $ 		 	
3	$	$	$
4	$	$	$
5	$	$	$

Retroactive Date of current policy:

32	Please state coverage Limits and Deductibles required:

A	Coverage Limits of Liability	$    		B  Self Insured Retention	$  	

The Applicant declares that, after enquiry, to the best knowledge of all persons to be insured the statements set forth herein and in any attachments made hereto are true and no material facts have been suppressed, omitted or mis-stated.

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 a policy is issued.

This application is signed on behalf of all Owners, Principals, Partners, Shareholders, Directors and Employees.

Must be signed by Owner, Partner or Officer:

Authorised signature of applicant	Title

Date
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